Sociocultural Framework for Psychiatric Case Formulation

Abstract

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.

Full text

Sociocultural Framework for Psychiatric Case Formulation
Mitchell G. Weiss, MD, PhD,*†Ankita Deshmukh, MSc, MPhil,‡
Sanjeev B. Sarmukaddam, MSc, DBS, MPS, PhD,‡and Vasudeo P. Paralikar, MD, PhD‡
Abstract: ACultural Formulation Interview (CFI) field trial in India, widely re-
ported 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). Con-
sequently, we revised the OCFas a sociocultural formulation (SCF) to better con-
sider structures of society and culture. We studied and compared clinicians' rat-
ings of SCF case formulations from a constructed assessment instrument (SCF
Interview [SCFI]) andthe CFI. Socio-cultural formulations from SCFIinterviews
were rated higher for details of societal structural impact, and overall interrater
agreement was better. CFI interviews were rated higherfor clinical rapport. Revi-
sion of the CFI should enhance consideration of structural issues and incorporate
them in SCFs that better integrate assessment process and case formulation con-
tent. 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.
Key Words: Outline for Cultural Formulation (OCF), Cultural Formulation
Interview (CFI), sociocultural formulation (SCF), structural competency, social
medicine
(JNervMentDis2024;212: 16–27)
The proposition of a cultural formulation, introduced in the Diag-
nostic and Statistical Manual of Mental Disorders (Fourth Edition)
(DSM-IV), helped to make values and principles of cultural psychiatry
visible to the mainstream profession. Case formulation in psychiatry
is an activity that applies clinical theory and practice frameworks
to information from clinical assessment of patients. It organizes rel-
evant issues to help clinicians understand their patients' problems
and to guide clinical care (Eells, 2022a). Various ways of constructing
a case formulation reflect the orientations and priorities of assessment
and treatment according to various interests or schools of psychiatry
—e.g., criteria-based diagnostic formulation in objective-descriptive
psychiatry; psychodynamic formulation in psychodynamic therapy
and psychoanalysis; and other particular case formulations for cognitive-
behavioral, interpersonal, family, and existential-humanistic psychiatry
(Eells, 2022b; Havens, 1987; Semple and Smyth, 2013). In the field of cul-
tural psychiatry, the Outline for Cultural Formulation (OCF), included in
the DSM-IV in 1994, provided a framework for cultural formulation
(Mezzich et al., 1999), and over the last decade, comparable interests
focusing on structural priorities have provided a framework for structural
formulation based on structural competency and principles of social med-
icine (Metzl and Hansen, 2014).
The OCF consisted of four topical domains and a fifth for syn-
thesis and practical implications. It has been used for published cultural
formulation case reports and clinical vignettes for residency training
program curricula in cultural psychiatry in North America and globally
(Lewis-Fernández et al., 2014; Mezzatesta Gava et al., 2022;
Venkataramu et al., 2021). The OCF was the required framework for
many published case studies, including a series of case reports as cul-
tural formulations in the journal Culture, Medicine and Psychiatry
(Lewis-Fernández, 1996). Initially, tools for constructing OCF-based
cultural formulations were unspecified (Mezzich et al., 2009), and the
Cultural Formulation Interview (CFI) was developed as a clinical in-
strument to provide such a tool. The CFI was published in a chapter
of the Diagnostic and Statistical Manual of Mental Disorders (Fifth
Edition) (DSM-5)on“Cultural Formulation”in 2013. In the DSM-5
Text Revision (DSM-5-TR), published in 2022, the CFI is included in
a section on “Cultural Formulation”of the retitled chapter, “Culture
and Diagnosis.”The link between CFI assessment and construction of
an OCF-based cultural formulation is implicit but not so clear as with
diagnostic instruments, such as the Structured Clinical Interview for
DSM-5 (SCID-5), comprising queries based on diagnostic criteria of
the DSM-5 to make a diagnosis (First et al., 2015).
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. But questions were less atten-
tive to other domain-related interests of the OCF (Table 1).
Second, it was difficult to distinguish social interpersonal issues
in the CFI and OCF from structural issues, which were relatively
neglected. The DSM-5-TR describes psychosocial issues of the third
domain of the OCF as “the influence of family, friends, and other com-
munity members (particularly, the individual's social network) on the
individual's illness experience”(American Psychiatric Association,
2022, p. 862). It thereby emphasizes social interpersonal issues without
explicit attention to enduring structural features of society and culture
that media attention subsequently brought to widespread public aware-
ness (e.g., racist policing and the murder of George Floyd in the United
States, and caste-based and religious communal violence in India).
Such issues represent key concernsof structural competency in medical
education and clinical care for assessing and addressing social determi-
nants of mental health problems in a number of US psychiatric resi-
dency programs (Hansen and Metzl, 2019a)
Psychiatry and Structural Issues in the United States,
India, and Other Countries
Previously neglected in both mainstream and cultural psychiatry,
in both the United States and India, a broad range of structural factors,
which are essentially societal and cultural, shapes various forms of dis-
crimination involving denial of political access, economic opportunities,
*Swiss Tropical and Public Health Institute, Allschwil, Switzerland; †University
of Basel, Basel, Switzerland; and ‡KEM Hospital Research Centre, Pune,
Maharashtra, India.
Send reprint requests to Mitchell G. Weiss, MD, PhD, Department of Epidemiology
and Public Health, Swiss Tropical and Public Health Institute, Kreuzstrasse 2,
4123 Allschwil, Switzerland. E‐mail: mitchell-g.weiss@un ibas.ch.
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. Thisis an
open-access article distributed under the terms of the Creative Commons Attribution-
Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is per-
missible to download and share the work provided it is properly cited. The work
cannot be changed in any way or used commercially without permission from
the journal.
ISSN: 002 2-3018/2 4/21201–0016
DOI: 10.1097/NMD.0000000000001721
ORIGINAL ARTICLE
16 www.jonmd.com The Journal of Nervous and Mental Disease •Volume 212, Number 1, January 2024

and human rights, including access to livelihood, financial and educa-
tional opportunities, and health services. In the United States, experiences
of gender, LGBTQ, and racial discrimination are substantial, and they are
clinically nuanced (Moody et al., 2023; Seelman et al., 2017). In
India, caste and communalism are also well known to affect mental
health in various ways (Gupta and Coffey, 2020; Kannuri and Jadhav,
2021; Mandal, 2022). In both the United States and India, these and
other cultural forms of systemic discrimination share commonalities
(Wilkerson, 2020).
Outside the United States and India, the psychiatric significance of
societal structural issues has been highlighted in various ways in various
countries and regions, both historically and presently. In the UK, Aubrey
Lewis, who has been said to have transformed social medicine into social
psychiatry, guided a committee emphasizing “the relevance to psychiatry
of poverty, unemployment, old age, workers' compensation, social failure”
and so forth for the Beveridge Report in 1942, which laid the groundwork
for the National Health Service in 1948 (Shepherd, 1980, p. 214).
Basaglia's law in 1978 transformed the structure of mental health care in
Italy from reliance on mental hospitals to community mental health ser-
vices (Piccinelli et al., 2002), and this deinstitutionalization influenced pol-
icy in the United States and throughout the world (Lanzotti et al., 2022).
In several countries of South America, advocacy and efforts to
implement the community-based approach, however, were notably
contested by opponents, who favored hospital care and biological psy-
chiatry (Castaldelli-Maia, 2022). These conflicts resonated with the ad-
vent of liberation theology, which involved questioning the impact of
social hierarchies and influence of the Catholic church in the region.
Paul Farmer argues that the “implications of liberation theology, how-
ever, for medicine and health policy”in Latin America have been “al-
most completely overlooked”(Farmer, 2003, p. 141), and he proceeded
to show how important the movement is for global health owing to its
focus on unmet needs of impoverished and oppressed people. In the
field of mental health, appreciation of the impact of structural features
of inequitable societies in Latin America may have contributed to de-
velopment of person-centered psychiatry, which aimed to shift the fo-
cus of clinical assessment “from disease and patient to person”
(Mezzich et al., 2016, p. 2).
In Australia, writing from the perspective of clinical psychology
rather than psychiatry, Bernard Guerin's exposition on social action for
mental health was the concluding volume of a six-book series, Exploring
Environmental and Social Foundations of Human Behavior (Guerin,
2020). The principles and approach resonate strikingly with the struc-
tural competency framework in the United States. The work of Guerin
and developers of structural competency are also both notable for the
influence of prior studies of racism in their respective settings (Metzl
and Roberts, 2014; Ngo and Guerin, 2017).
Social Medicine, Structural Violence and
Structural Competency
The field of social medicine, conceived as an interface of medical
and social sciences (Porter, 1997), and its recent implementation in psychi-
atry as structural competency are directly concerned with identifying and
addressing various forms of discrimination and deprivation affecting so-
cially disadvantaged patients. The work of Paul Farmer emphasizes the role
of structural violence to explain how structures of society and culture affect
patients and clinical priorities (Farmer, 2004). The concepts of structural vi-
olence and cultural violence were initially developed by Johan Galtung as a
framework for peace studies and advocacy for human rights (Galtung,
1969, 1990), and he also recognized they were broadly applicable to health
studies and other social issues. Galtung (1990) understood peace as the op-
posite of violence, and he explained cultural violence as “those aspects of
culture…that can be used to justify or legitimize direct or structural vio-
lence.”Cultural, structural, and direct violence constituted an interrelated
triad. “Cultural violence makes direct and structural violence look, even
feel, right—or at least not wrong”(Galtung, 1990, p. 291). In the clinical
context of health studies, the typology of violence Galtung proposed for
peace studies is analogous to societal structural health impairment elabo-
rated in the field of social medicine, which is concerned with cultural ideas
about racial and ethnic groups and gender issues, and the influence of laws,
regulations, and practices affecting discrimination, social disadvantage, and
health problems.
In the early years of modern cultural psychiatry, before the
1980s, social medicine did not figure prominently. In fact, conceptualiza-
tion of the interrelationship of culture, medicine, and psychiatry notably
disregarded social medicine. Kleinman acknowledged that seminal de-
velopments in formulating that conceptualization had their “beginnings
not in Social Medicine, but in the space between Anthropology and
TABLE 1. Relationship of CFI Questions to Domains of the OCF
Abridged Questions of CFI
Implied OCF Domains
I. Cultural
Identity
II. Concepts
of Distress
III Psychosocial
Stressors
IV Relationship
With Clinician
1 How would you describe your problem? X
2 How would you describe your problem [to others]? X
3 What troubles you most about your problem? X
4 What do you think are the causes of your problem? X
5 What do others think is causing your problem? X
6 Are there any kinds of support that help, such as family, friends or others? X X
7 Are there any stressors that worsen your problem, such as money, family problems? X X
8 What are the most important aspects of your background or identity? X
9 Do any aspects of your background or identity make a difference to your problem? X X
10 Any aspects of background or identity that cause other concerns or difficulties? X
11 What have you done on your own to cope with your problem? X
12 What types of help or treatment were most useful? Not useful? X
13 Has anything prevented you from getting needed help, e.g., money, work, family, etc? X X
14 What kinds of help do you think would now be most useful? X X
15 Have family, friends, or others suggested any other kinds of help? X
16 Have you any concerns about different backgrounds of you and your doctor? X
The Journal of Nervous and Mental Disease •Volume 212, Number 1, January 2024 Sociocultural Case Formulation
© 2023 The Author(s). Published by Wolters Kluwer Health, Inc. www.jonmd.com 17

Psychiatry, Medicine and Social Science”(Kleinman, 2021, p. 505).
Later, he acknowledged and emphasized structural determinants, espe-
cially political considerations in China. Kleinman wrote, “In China, dur-
ing the Cultural Revolution, psychiatrists were largely silent when their
patients were relabeled as exemplars of wrong political thinking”
(Kleinman, 1988a, p. 105), and he elaborated that point in various case
studies (Kleinman, 1988b, pp. 104–111).
Currently in Switzerland, suicidality among refugees seeking, but
not receiving, asylum status may present as a clinical problem of patients
fearing deportation back to countries where they had been targets of vio-
lence. Furthermore, relevant concerns are not restricted to such high-
profile dramatic events—such as internal and external displacement, rac-
ist policing that spawned the Black Lives Matter movement in the United
States, or violent instances of caste and communal violence in India.
More mundane instances of structural sources of emotional pain—
overt or implicit microaggressions, and encounters with inflexible
bureaucracies—also matter. Clinicians need to know how such structural
issues affect their patients' lives and experience, and a relevant framework
for case formulation should ensure they are considered.
Inattention to structural issues remains central to a critique of
cultural competency on which structural competency training is based
(Hansen et al., 2018). Introducing a collection of structural competency
programmatic case studies, Hansen and Metzl explained, “Cultural
competency focused mainly on identifying clinician bias and improving
communication at moments of clinical encounter”instead of the “eco-
nomic and political conditions”that structural competency emphasizes
(Hansen and Metzl, 2019b, p. xxiii). A series of clinical case studies in
social medicine, published in the New England Journal of Medicine
from 2018 to 2021, dealing with both medical and psychiatric issues,
illustrates the relevance and implications of that argument (Stonington
et al., 2018). The Cultural Committee of the Group for the Advance-
ment of Psychiatry has recognized neglect of the structural sources of
health impairment and aneed to expand the frameworks of cultural psy-
chiatry to ensure it remains relevant (Weiss et al., 2021).
Revised OCF as Sociocultural Formulation and
Development of a Sociocultural Formulation Interview
In this study, a sociocultural framework for case formulation in-
corporated cultural and structural dimensions attentive to not only the
cultural priorities of the OCF but also the structural priorities of social
medicine. The four domains of this sociocultural formulation (SCF)
framework are presented in Table 2. A patient-centered interview, the
SCF Interview (SCFI), was developed to directly address the four topical
domains of this SCF framework, providing patients an opportunity to re-
port their own experience of the impact of society and culture on their
lives and problems. Questions of this SCFI are presented in Table 3.
Like the CFI, questions of the SCFI have been formulated to in-
quire about all issues from the vantage point of patients. Because pa-
tients may be unaware of important structural issues that affect them,
other sources of information are also needed, and a treatment team with
relevant expertise may be valuable if available.
Also, patients may be inhibited and reluctant to respond forth-
rightly to questions about structural issues, their own illness explana-
tory models, and use of various other health care options out of concern
the clinician whose help they want may disapprove. The construction and
administration of the SCFI, the CFI, and EMIC interviews, which key as-
pects of the first two are based on, are mindful of requirements for careful
interviewer training, sensitivity in formulating questions, and the value of
strategically placed empowering introductions that “explain the nature of
the queries that follow and assure the respondent that responses will not
be a source of humiliation”(Weiss, 1997, p. 245). Such measures are
intended to ameliorate effectively, even if not perfectly, potential reluc-
tance of patients to respond comprehensively.
Objectives and Specific Aims of This Study
This study was undertaken to develop and evaluate a framework
for sociocultural case formulation, and to test and compare CFI and
SCFI assessment instruments. The following were specific aims:
1. To gain experience in clinical assessment interviews with the CFI and
SCFI for constructing case formulations based on the four domains of
the SCF framework (viz, cultural identity, explanatory models, social
interpersonal issues, and structures of society and culture).
2. To assess the level of detail and clinical relevance of case data for the
four topical domains of the SCF, and for the practical value of the
case formulation based on clinical rapport, implications for diagno-
sis, and guidance for case management.
3. To compare clinician evaluators' ratings of the SCF case formulations
from CFI and SCFI interviews for the level of detail and clinical rele-
vance of the four domains, and for the practical value of these
case formulations.
4. To compare the reliability of clinician evaluators' ratings of the do-
mains and practical significance of SCF case formulations based
on clinical data from transcripts of CFI and SCFI assessments.
METHODS
Setting, Patient Sample, and Clinician Evaluators
The study was conducted at two sites in Pune, India: the psychi-
atry outpatient clinic of the King Edward Memorial (KEM) Hospital, a
charitable trust hospital, and the private practice clinic of the project PI,
Dr. Paralikar. Pune is a major cityof Indiawith an estimated 2023 metro
area population of 7.2 million persons (Poona, India Metro Area
Population 1950–2023, 2023).
TABLE 2. Cultural and Structural Priorities in Four Domains of SCF
I. Cultural identity of the patient
•Passively acquired and affirmed: ethnic, national, and community
affiliations (aff irmed or denied)
•Personally acquired and affirmed: work-related, professional, and/or
other shared-interest groups
II. Illness explanatory model
•Experience: identification of problem, priority symptoms, patterns and
idioms of distress, stigma-related concerns
•Meaning: perceived causes (static and dynamic), acknowledging
uncertainty, variability, and significance
•Behavior: risk related, self-help, and help seeking (current and prior)
III. Key social relationships
•Family, work, community, and other significant social relations
•Anticipated relationship with clinician
•Significance regarding both life and/or problem
IV. Structures of society and culture (i.e., political, economic, health system,
and cultural settings)
•Minority and racial status, migration, refugee status, cultural norms,
social vulnerability, and entitlements
•Political economic stressors and supports; health system access
and experience
•Identified features of structural and cultural violence implicated as
structural sources of health impairment
•Impact of environmental issues, globalization, climate change,
exposures, use, and effects of social media
Summary with practical implications for rapport, diagnosis, and
case management
•Summary of significant features of SCF
•Implications for explaining relevant features of patient's life and
problems, including diagnosis and clinical care
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18 www.jonmd.com © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

Adult patients aged 18 to 80 years were recruited from the KEM
Hospital outpatient psychiatry clinic and fromthe private practice clinic
by quota sampling to obtain 30 patients at each site. Patients were assigned
alternately to CFI and SCFI interview groups. Acutely ill, suicidal, and
overtly psychotic patients were excluded. Potential participants were in-
formed about the research, and their informed consent was obtained for
the interview and audio recording. The presenting problems and diagno-
sis given by referring clinicians were noted. The study was undertaken
during the COVID pandemic, and patients were offered the opportunity
for online or in-person interviews with appropriate precautions.
Clinician evaluators of SCF case formulations included both per-
sonnel on the research team, designated as internal evaluators, and ex-
ternal evaluators. The structure and rationale of the SCF framework
was explained to them, and instructions were provided on how to doc-
ument their assessmentof transcripts on evaluation forms with their cat-
egorical ratings and qualitative comments.
Instruments
The DSM-5 version of the CFI is a 16-item semistructured interview
that was developed as a tool for cultural formulation (Lewis-Fernández
et al., 2016). We updated the Hindi and Marathi translations of the CFI
trial version, which had been used in our earlier validation study (Paralikar
et al., 2015), to incorporate changes in the DSM-5 published version.
The SCFI is a 24-item semistructured interview developed for
this study (Table 3). Questions are organized with reference to the four
domains of the SCF, namely, cultural identity, illness explanatory model,
key social relationships, and acknowledged impact of structural features
of society and culture. The interview was constructed in English and then
translated into Hindi and Marathi by the research team, and back-
translated by a consultant professor of English at Pune University.
An Evaluator Rating Form was developed for this study for clini-
cian evaluators to assess the detail and the relevance of clinical data based
on the four domains of the SCF, and practical signif icance for clinical
care with reference to clinical rapport, diagnostic relevance, and treatment
planning. Possible values for each of these ratings of detail, relevance,
and significance were none (0), low (1), moderate (2), and high (3).
Forms included space for notes for evaluators to explain their ratings.
Design
Psychiatric outpatients were interviewed with either the CFI or
the SCFI. Clinic fees were waived for the clinical consultation in which
the research interview was conducted, and patients were offered com-
pensation of Rs 300 (USD 3.50) for their time. Case formulations based
on domains of the SCF were prepared from transcripts. For each inter-
view, one internal and two external clinician evaluators rated the level of
detail and relevance of clinical information in the four domains of the
SCF and the practical value of the SCF case formulation. They also pro-
vided qualitative notes to explain their rating.
Data Management and Analysis
Clinical interviews were audio recorded and translated into
English, and transcriptions were entered and coded in MAXQDA. Cod-
ing identified the questions of both interviews that elicited clinical data
relevant to the SCF framework. Ratings of internal and external
TABLE 3. Questions of the SCFI Developed for Clinical Assessment Based on Topical Domains of the SCF
SCF Domains and Associated Questions of the SCFI (Abridged)
I Cultural identity
I-1 What are the most important aspects of your background or identity?
I-2 Are any features of your background and identity a source of pride and satisfaction?
I-3 On the other hand, are there any that are matters of concern or difficulty for you?
II Illness explanatory model
II-1 Do you have a name for your problem? How would you describe it to someone?
II-2 What troubles you most about it, and how does it affect your life?
II-3 What factors do you think explain your problem?
II-4 Have you done anything for yourself or in response to suggestions of family or friends? Tell me how it did or did not help.
II-5 What doctors, healers, or helpers have you seen for your problem? What kind of experience was that?
II-6 At this point, what do you think is most likely to be helpful? Do you expect full cure, little help, or something else?
II-7 Do relatives or other people close to you have any different ideas about your problem or what should be done for it?
III Key social relationships
III-1 Who are the people most important to you? How would you describe their relationship to you?
III-2 How helpful have they been, and how helpful are they likely to be?
III-3 How satisfied are you with the quality of social relations (e.g., family, friends, sexual partners, and others)?
III-4 On the other hand, are there people who have, or are likely to, make matters worse?
III-5 Is it important that the clinicians are of the same religion or caste, gender, or sex, or that they have a cultural or political background similar to yours?
IV Structures of society and culture
IV-1 Do environmental factors (crowding, pollution, traffic, etc.) affect your life and problem?
IV-2 Are the requirements of your religion, caste, or culture mainly helpful or a hindrance?
IV-3 Are you satisfied or troubled by community, work, school, social, or financial status?
IV-4 Are you satisfied with the health, banking, and other services available to you?
IV-5 Do you think you face problems or discrimination based on your religion, caste, being a man or woman, or anything else related to who you are?
IV-6 Are any of your ideas or political views considered unacceptable by other people who can make your life difficult?
IV-7 Issues like obtaining identity cards, getting the money you need to live, and so forth may be troubling. Have you had difficulty dealing with any issues
like that, which may result from complicated or exclusionary policies, regulations, or laws?
IV-8 Do you have any concerns about threats to your safety and security?
IV-9 Have you been troubled by any of the various developments resulting from mobile and internet technologies in our changing world?
The Journal of Nervous and Mental Disease •Volume 212, Number 1, January 2024 Sociocultural Case Formulation
© 2023 The Author(s). Published by Wolters Kluwer Health, Inc. www.jonmd.com 19

evaluators for detail and relevance with reference to the four domains,
and with reference to three indicators of practical value were entered into
an Excel database for quantitative analysis, and qualitative notes were
also entered into MAXQDA.
Ratings of the one internal and two external evaluators were
pooled for each patient, and a mean rating for each item was used for
analysis of the level of detail and clinical relevance of the four domains,
and for the three indicators of practical value. Composite summaries for
detail, clinical relevance, and practical value were also computed, as
was an overall summary based on the 11 ratings.
Illustrative features of SCF case formulations, based on evalua-
tors' assessments, were selected to indicate the rationale for high and
low ratings. Quantitative ratings of level of detail and clinical relevance
of the four SCF domains and ratings for significance were compared for
CFI and SCFI interviews using the Mann-Whitney test for significance.
We also examined the agreement of the three raters for each item of the
SCF that was rated (11 items), for the three composite summaries, and
for an overall summary of the 11 items, comparing the intraclass corre-
lation coeff icients (ICCs) for evaluators' agreement on ratings of items
of SCF case formulations for CFI and SCFI interview groups.
RESULTS
Patient Sample
Study patients (N= 60) had a median age of 34 years (mean,
39.6; SD, 13.1). The sample included 28 men, 31 women, and 1 iden-
tifying as trans nonbinary. On average, interviews lasted for an hour
(mean, 70.3 minutes; SD, 24.0; median, 71.5 minutes). Ten interviews
were conducted online and 50 were face to face. Sample characteristics
of the two groups were similar (Table 4).
Evaluators
Internal evaluators were qualified junior psychologists, and ex-
ternal evaluators included one senior clinical psychologist and eight
psychiatrists. External evaluators had clinical experience ranging from
4 to 31 years. Six were consultant psychiatrists at the KEM Hospital
and two were department heads of other medical colleges in Pune.
Six had experience in previous clinical cultural research studies in
Pune, including four with prior experience in the Pune site field trial
of the CFI, one in earlier cultural epidemiological studies using EMIC
interviews, which were precursors of the CFI and SCFI (Weiss,
2017), and one who had experience in both. SCF case formulations
based on interview transcripts for patients previously unknown to them
were provided for their evaluations.
Level of Detail, Clinical Relevance, and Practical
Significance of Ratings for Case Formulations
Evaluators rated both the level of detail and the clinical relevance
of information in each of the four domains, and they rated the three indica-
tors of practical value. Table 5 provides illustrative excerpts from evalua-
tors' comments that indicate their rationale for high and low ratings of each
of these categories. Evaluators referred to the richness of interview tran-
scripts elaborating on content of the topical domains to explain ratings
for level of detail. Their ratings of clinical relevance indicated whether they
could usefully interpret and apply available content based on their clinical
experience. Comments indicating the rationale for high ratings for clinical
rapport also referred to the style and layout of the interview.
The mean values of the average of the threeevaluators' subjective
ordinal ratings for domains of the SCF framework and indicators of the
clinical value of the case formulation are summarized in Table 6. Com-
posite ratings for detail and relevance of the four domains and for the
three indicators of clinical significance, and an overall summary based
on all 11 ratings were also computed and compared. Evaluators rated
the value of interview data in the transcript for each category as high
(3), moderate (2), low (1), or none (0). Ratings for level of detail for three
of the four domains were in the moderate-to-high range for both CFI and
SCFI interviews; for the fourth domain, structures of society and culture,
however, level of detail was rated in the moderate-to-high range only for
SCFI interviews but in the low-to-moderate range for CFI interviews.
Clinical relevance of structures of society and culture was rated in the
low-to-moderate range for both CFI and SCFI interviews, although
higher for the SCFI interview group. The summaries for detail, relevance,
clinical value, and all 11 items were in the moderate-to-high range for
both interview groups without significant differences.
As an indication of the reliability ofassessment for SCF case for-
mulations, we examined the agreement of the three evaluators' ratings
for each rated category, and for summaries of detail, relevance, clinical
value, and all rated items. We compared the ICCs for the ordinal ratings
in the two interview groups (Table 7). For all rated categories, agree-
ment was higher for patients in the SCFI interview group except for
clinical rapport, for which agreement was nearly the same for the two
interview groups. For the SCFI interview group, the level of detail of
all domains except the illness explanatory model had excellent or good
agreement. For the CFI interview group, the best agreement was only
fair for four categories butpoor for the remaining seven. For SCFI inter-
views, agreement was poor for two categories, and for the rest, it was
fair, good, or excellent. Note however that conf idence intervals were
wide and overlapping for all interview group comparisons, although
less so for agreement of composite summaries of detail and relevance
of the domains, and for indicators of the practical value of the SCF case
formulation. For the overall summary of all assessed items, agreement
was fair for the CFI group and good for the SCFI group.
DISCUSSION
As the need to incorporate values of structural competency in
psychiatry has become more apparent, “questions about the extent to
which the CFI suff iciently addresses this important aspect of culturally
competent assessment and care”have become more relevant (Jarvis
TABLE 4. Patient Sample Characteristics
Category Classification CFI (n=30) SCFI(n=30)
Age, yr Mean 42.1 37.0
SD 13.7 12.1
Range 23–75 23–65
Sex Male 12 16
Female 18 13
Nonbinary 0 1
Marital status Married 22 16
Living together
unmarried
11
Unmarried 4 9
Divorced 2 4
Widowed 1 0
Religion Hindu 22 24
Muslim 5 1
Others 3 5
Education, yr Mean 13.4 16.1
SD 5.4 5.4
Range 3–26 7–36
Mode of interview Online 4 6
In-person 26 24
Duration of interview
(minutes)
Mean 66 75
SD 25 23
Range 31–129 21–112
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TABLE 5. Evaluators' Illustrative Comments Indicating Rationale for Their Highest and Lowest Ratings
a. Level of Detail of Domain Content
Domain Rated 3 (High Value) Rated 0 (No Value)
Cultural identity There is a high amount of detail for the questions…which capture
the essence of what cultural identity means to this individual.
Key features like language, background, caste, nationality, gender,
community and so on are covered in a good amount of depth.
The amount of information available is very limited….The
patient answers in either affirmative or negative with very short
sentences limiting the amount of information and depth.
Illness explanatory
model
There is a wide coverage of this domain ranging from clearly
labeling the illness, describing the symptoms, possible causes,
treatment history as well as many other facets that are
relevant to this domain. There is chronological history covered
about the illness. Coping is also covered in depth.
Not of much relevance as little is known about the dynamics.
Social relations Most of the interview spans this aspect or domain. Every question
in the interview somehow circles and points to key social
relationships and their role in this person's life. There are
therefore extensive amounts of relevant information available
to the clinician.
The patient gives more or less monosyllabic responses, and
therefore no information as such of any depth is elicited.
Nothing new which was not elicited previously in the other
domains comes through here.
Structures of
society and
culture
The patient gives a very good description of how the immigration,
job, and financial situation affected her when she was in the
US. I felt almost all questions helped to bring this out very
nicely. Some questions about politics, terrorism, etc. were less
useful in this particular case.
There is almost no detail in the answers elicited in this domain of
societal structural context. Short answers without depth are
provided by the patient. Barely any key features elicited in
response.
b. Clinical Relevance of Domain Content
Domain Rated 3 (High Value) Rated 0 or 1 (No Value or Low Value)
Cultural identity These factors about her identity could have relevance to
clinical care as well as her life. The female stereotypical role
she is expected to play has a role in her illness, and anger
management skills.
There is almost no information of any value elicited in
this domain…. There is a brief mention of Tamil as his
mother tongue…. Overall, there is no insight available for
the clinician.
Illness explanatory
model
The patient attributes the cause of her illness to varied things….
As a clinician this gives indication to how much motivation
and compliance the patient is likely to have. The main body
of information…shows…the role of the marital relationship….
This in my opinion is very relevant clinically.
Difficult to correlate the narrative with clinical symptoms and
planning management.
a
Social relations The importance of the positive and negative effects of the key
relationships in this patient's life are available scattered all
throughout the interview. The strong negative impact of her
relationship with her mother in law, lack of support and
understanding from her father and husband.
There is very low or almost no clinical relevance of the
information elicited in this domain of the interview. All the
clinician can gather from the data is that this patient enjoys
good and healthy relationships with everyone around her.
There is therefore limited coverage, depth and insight that
comes from this part of the interview.
Structures of
society and
culture
Financial difficulties leading to lack of access to good facilities
ike transport are described…. The usual norms and values
expected from a husband, sons and daughter laws - and the
duties which are neglected by them towards her are discussed
repeatedly in this interview, helping the clinician understand
the depth of trouble it causes her…. [Inability] to be financially
independent leading to being discriminated against is
also highlighted.
There is none to very little information elicited in this domain.
There is some mention of attending mass, some religion-based
discussions in groups in college, a few hindrances due to
environmental factors, but none offer any insight or coverage
which is of value to the clinician.
c. Practical Value of SCF Case Formulation
Indicator Rated 3 (High Value) Rated 0 (No Value)
Clinical rapport The interview, style and questioning layout significantly contribute to
the clinical rapport…. Amply clear from the flow and quality
of information available to the clinician…. Cultural identity,
key social relationships clearly demonstrate the strong rapport.
Every question asked is weighed and answered. Very few questions
are dismissed…. Effort taken to reply in detail is indicative of a
positive interview format.
The domains of questions don't contribute much to the clinical
rapport. If at all, there is some information
elicited in the domain of illness explanatory model, but in a
limited manner.
(Continued on next page)
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et al., 2020, p. 45). But consideration of structural issues was not a pri-
ority in its development and has not yet been adequately considered in
either the OCFor the CFI. Our study showed that structural issues could
be included in the framework for case formulation by revising the OCF
as SCF to include patients' acknowledged impact of the structures of so-
ciety and culture as a topical domain.
We found that clinician evaluators who rated the case formula-
tions derived from assessments with either instrument ascribed moder-
ate to high value for nearly all elements of the SCF framework. Al-
though both interviews worked well for the most part in eliciting data
that were sufficiently detailed, clinically relevant, and having practical
value (Table 6), notable differences among several ratings reflected dif-
ferent motivations for developing the two instruments. In assessing the
role of structural issues in SCF case formulations with the SCFI, the
level of detail in patients' accounts was rated in the moderate-to-high
range and significantly higher than ratings for structural detail based
on CFI interviews, which was rated in the low-to-moderate range
(2.21 vs. 1.64, p<0.0001).
Although the SCFI was better able to elicit details about struc-
tural issues, as it was designed to do, the clinical relevance of structural
issues was rated in the low-to-moderate range for both CFI and SCFI
interview groups. Failure to attribute clinical relevance, despite ac-
knowledging elicitation of detail, may reflect inattention to structural is-
sues in clinical training and practice experience of the clinician evalua-
tors. It was not clear to them what to dowith information, even detailed
information, about structural issues. Structural competency training to
assess and use such information is needed, and some psychiatry resi-
dency programs are developing training curricula to do that (Hansen
and Metzl, 2019a; Metzl and Hansen, 2018). They aim to impart bench-
mark skills to identify and address structural issues affecting patients'
problems by “rearticulating ‘cultural’formulations in structural terms”
(Metzl and Hansen, 2014). Our study shows that the SCF may be used
for that, to harmonize cultural interests of cultural psychiatry and struc-
tural interests of social medicine through a patient-centered lens.
Ratings for clinical rapport were significantly higher for the CFI
group compared with the SCFI group. Both were in the moderate-to-
high range but closer to high for the CFI group and closer to moderate
for the SCFI group (2.60 vs. 2.33, p= 0.029). The higher rating for clin-
ical rapport for the CFI reflects priorities of development of the CFI,
focusing on interview process, and the benefits of more extensive experi-
ence refining it for that purpose in extensive pilot testing and international
field trials. Priorities of the validation studies—feasibility, acceptability,
and usefulness—focused squarely on the priority of clinical rapport to
justify its inclusion in the DSM-5 (Jarvis et al., 2020; Lewis-Fernández
et al., 2020).
Reliability
Despite less experience in development and refinement of the
SCFI, its design and structure resulted in better interrater agreement
among the three evaluators. The ICC for evaluators' ratings of
CFI-based SCFs showed agreement no better than fair for 4 of the 11
TABLE 6. Mean of Three Evaluators' Ratings for Components of the
SCF Case Formulation Based on Data From Clinical Assessment With
the CFI and SCFI
Category CFI SCFI Significance
Levelofdetailoffourdomains
Cultural identity 2.13 2.36 *
Illness explanatory model 2.56 2.49
Social relations 2.36 2.27
Structures of society and culture 1.64 2.21 ***
Summary for detail (4 items) 2.17 2.33
Clinical relevance of four domains
Cultural identity 2.02 2.23
Illness explanatory model 2.36 2.51
Social relations 2.39 2.18
Structures of society and culture 1.59 1.81
Summary for relevance (4 items) 2.09 2.18
Practical value of SCF case formulation
Clinical rapport 2.60 2.33 **
Diagnostic significance 2.24 2.13
Treatment implications 2.33 2.33
Summary for value (3 items) 2.39 2.26
Overall summary
All ratings (11 items) 2.20 2.26
N= 30 for CFI and SCFI interviews (total, 60). Ratings for domain detail, do-
main relevance, and practical significance: high (3), moderate (2), low (1), and
none (0). Values for each item are mean ratings of one internal and two external
evaluators. Summary mean values of assessed items are in italics. Higher values
are indicated in bold for each comparison. Indicated significance is based on the
Mann-Whitney test: *p<0.10, **p< 0.05, and ***p< 0.01.
TABLE 5. (Continued)
c. Practical Value of SCF Case Formulation
Indicator Rated 3 (High Value) Rated 0 (No Value)
Diagnostic
significance
The interview provides a high level of insight into the diagnosis.
The associated suffering, role of biological factors, stressors
and coping helps the clinician gain good understanding.
The almost uncontrollable ruminations around loss of
autonomy, role of family members indicates to the clinician
what challenges this patient is facing.
I don't think so. It may in fact increase the diagnostic dilemma.
This is mainly due to lot of redundant information.
Treatment
implications
This interview provides good insight into the condition of the
illness and offers valuable input about what treatment
planning needs to be done. Cognitive therapy, anxiety management
methods, and radical acceptance will help this patient
tremendously. Cognitive restructuring around expectation and
reality w ill b e use ful.
The lack of depth in this interview also presents a challenge
for planning treatment. Some answers definitely help indicate
some key treatment points - like the poor quality of
relationships, his personality, his illness etc., but at best.,
they are experienced guesses from the clinician. This
interview does not provide much value to have a clear
treatment plan ready
a
Comment explaining the relevance of illness explanatory model rated “1”was included because there was no rating of “0”.
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ratings, and poor for the remaining 7 ratings. For the SCFI, however, the
ICC was at the level of good for the overall summary of all 11 ratings,
good for composite ratings of the clinical relevance of four domains,
and excellent for composite ratings of the level of detail of four domains
(Table 7). This may be explained by the topical specificity of SCFI
questions linked to domains of the SCF.
Constructing the SCFI for assessing SCF domains for a content-
based SCF achieved levels of interrater agreement comparable to reli-
ability studies using SCID-5-CV interviews. SCID interviews comprise
questions with a comparable strategic focus on diagnostic criteria, which
facilitates reliability in diagnostic assessment. Our findings included
ICC estimates for interrater agreement with SCFI interviews similar
or close to the values of the Kappa statistics for interrater agreement
of SCID-based diagnoses in various settings (Osório et al., 2019;
Shabani et al., 2021), but ICC values were much less for CFI-based
SCF case formulations.
It should be noted, however, that the SCFI is similar to the SCID
only insofar as questions focus clearly on priorities of their respective
frameworks for sociocultural and diagnostic case formulations. But in
other ways, they are fundamentally very different. Both the CFI and the
SCFI provide what is essentially clinical ethnographic information in
prose to construct case formulations based on respective frameworks of
the OCF and SCF. The SCID, on the other hand, is used to evaluate diag-
nostic criteria of the DSM to make a categorical judgment, i.e., a diagno-
sis. In our study, however, we analyzed ordinal ratings of the detail, rele-
vance, and value of SCF case data, which as clinical ethnography consist
of prose content rather than binary judgments of diagnostic criteria.
Poor interrater agreement in ratings of the level of detail and clin-
ical relevance of illness explanatory models was striking, because mean
ratings of both detail and relevance were moderate to high for both CFI
and SCFI interviews. Implications are not necessarily clear, but this
finding may suggest that although explanatory models are well known
and highly valued for a patient-centered assessment, interpreting the
clinical significance of an explanatory model for a particular patient
is not so clear, and it requires further clarification as a priority for cul-
tural competency training.
Cultural Contexts
Clinician evaluators appreciated information about cultural con-
text. The high rating for detail on cultural identity was explained for an
illustrative patient as follows: “Key features like language, background,
caste, nationality, gender, community and so on are covered in a good
amount of depth”(Table 5). Cultural and structural issues are informa-
tive, and our SCF-based case formulations may be construed as a tenta-
tive structured clinical ethnography that begins with initial assessment.
Critical of inattention to context in the clinical assessment of explana-
tory models, Kleinman and Benson (2006) had earlier recommended
use of “mini-ethnography,”proposing a six-step approach for “arevision
of the Cultural Formulation.”Cultural and structural content of our SCF
case formulations are suitable for both setting-specific elaboration and
cross-cultural comparisons in other areas of India and globally.
Consideration of caste provides an example. It is an important issue
in India, which may be shaped by regional features affecting its impact.
Caste was a key issue for one of our patients, who emphasized differences
in her own and her clinician's recognition of its impact. The influence of the
Indian diaspora, and global interest in the relationship between caste, rac-
ism, and other forms of discrimination, has led to interest in the social, po-
litical, and economic impact of caste beyond India (Wilkerson, 2020). In
the United States, recent legislation explicitly prohibited caste discrimina-
tion in Seattle, eliciting press coverage and comments on political implica-
tions in the United States, India, and throughout the world (Datta, 2023;
Murray, 2023; Sengupta, 2023).
The relevance of various cultural and structural issues in our case
data is well worth elaborating further, as they were in the pilot study of
the CFI, which indicated the need to revise the OCF (Paralikar et al.,
TABLE 7. Agreement Among Three Evaluators for Ratings of SCF Categories Using ICC for Comparing Patients Assessed With CFI and SCFI
Category
CFI SCFI
Estimate 95% CI Estimate 95% CI
Level of detail of four domains
Cultural identity 0.39 −0.13 0.69 0.65** 0.35 0.82
Illness explanatory model 0.31 −0.26 0.65 0.32 −0.24 0.66
Social relations 0.44** −0.03 0.71 0.75*** 0.55 0.88
Structures of society and culture 0.01 −0.81 0.50 0.64** 0.33 0.82
Summary for detail (4 items) 0.46** 0.01 0.72 0.76*** 0.56 0.88
Clinical relevance of four domains
Cultural identity 0.25 −0.38 0.62 0.44*−0.03 0.71
Illness explanatory model 0.09 −0.67 0.54 0.29 −0.31 0.64
Social relations 0.46* 0.01 0.72 0.59* 0.24 0.79
Structures of society and culture 0.44* −0.04 0.71 0.47* 0.04 0.73
Summary for relevance (4 items) 0.39 −0.11 0.69 0.61** 0.29 0.80
Practical value of SCF case formulation
Clinical rapport 0.44*−0.02 0.72 0.43* −0.04 0.71
Diagnostic relevance 0.11 −0.64 0.55 0.50* 0.09 0.75
Treatment implications 0.01 −0.82 0.49 0.43*−0.05 0.71
Summary for value (3 items) 0.29 −0.31 0.64 0.62** 0.30 0.81
Overall summary
All ratings (11 items) 0.44*−0.03 0.71 0.73** 0.50 0.86
Ratings of three evaluators, one internal and two external, for 30 patients in each assessment group. Summary of mean values of assessed items are in italics. Higher
estimates are indicated in bold format. Agreement is interpreted according to accepted criteria for estimates of ICC(Cicchetti, 1994). They are indicated for estimates as
follows: excellent (>0.75), good (0.60 –0.74), fair (0.40 -0.59), and poor (<0.40).
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2020). Presentation and analysis of the content of our SCF case formu-
lations, however, are beyond the scope of this report, which isprimarily
concerned with rethinking the OCF as SCF.
Complementary Relevance of Interview Content and
Process for Case Formulation
Case formulations involve dual interests that contribute to clinical
care: formulation process and formulation content. The complementary
nature of the two has been more explicit in the literature on case formu-
lation for other areas of psychiatry than for cultural psychiatry. A hand-
book on psychotherapy case formulation provides a working definition
that explains this point: “Case formulation involves both content and
process aspects”(Eells, 2022a, p. 3). In our study, benefits of process
are indicated explicitly by evaluators' ratings that acknowledge the value
of clinical rapport, and implicitly by evaluators' appreciation of the level
of detail elicited in the content of case formulations.
The process of engaging patients around issues they consider im-
portant enables them to share subjective lived experience, which may be
essential for building trust and creating a therapeutic alliance (Braslow,
2021). Such consideration of empathic process has historically been a
fundamental priority for schools of phenomenology and existential
psychiatry, associated with the contributions of Karl Jaspers (Jaspers,
1968), Ludwig Binswanger (Binswanger, 1963), Rollo May (May
et al., 1958), and others (Stanghellini et al., 2019). Recent reports
highlighting the value of innovative methods based on principles of
phenomenological psychiatry demonstrate current recognition of the
value of process in patient-centered clinical care (Fusar-Poli et al.,
2022; Sass, 2022).
Over the years since the proposition of cultural formulation was
introduced in the DSM-IV, the nature of cultural formulation has been
understood in different ways. Initially, it was a case summary based
on the framework of the OCF, which was constructed from information
obtained in unspecified ways. In the DSM-5, the CFI was included as a
process for constructing a cultural formulation, explained as “an interview
protocol designed to be used by clinicians in any setting to gather essential
data to produce a cultural formulation”(Jarvis et al., 2020, p. 40).
Reported benefits of the CFI refer to its value for eliciting details
that might otherwise be missed or misunderstood; the value of the CFI
is also described with reference to process benefits that enhance patients'
trust in a therapeutic alliance (Aggarwal et al., 2022). Some accounts go
farther, suggesting the process of administering the CFI may be regarded
not just as an assessment but also as an intervention, even referring to
“operationalized dosage by quantifying the total length of time of the
CFI session”as a metric to maximize benefits of the session, “permitting
future intervention research”(Aggarwal et al., 2014, pp. 1403–1404).
Notwithstanding the recognized benefits of process, the value of
the CFI as an interview process has superseded the priority of eliciting
content for a cultural formulation as a product, which had initially mo-
tivated its development. Efforts to call attention to patients' experience
of structural issues in our study underscore a need to restore the balance
of process and content, facilitated by use of SCF case formulations in
case summaries, treatment planning, and clinical communications.
Implications for Further Development of the CFI
Although the SCFI interview was developed to address identified
shortcomings of the CFI, the contributions and dominance of the CFI are
clear. Efforts to develop it, its inclusion prominently in the DSM-5, and
widespread appreciation of experience using it are compelling. Neverthe-
less, several findings of our study are relevant for further development of
the CFI, so that it can fulfill its original aims. First, inasmuch as the CFI
did not elicit details of structural issues as well as the SCFI, revision is
needed to make the CFI more attentive to various forms of structural
and cultural violence resulting from the impact of society and culture.
Second, strategies for use of the CFI as an assessment instrument should
be developed to distinguish process benefits of administering the CFI and
use of interview findings as products of assessment in case formulations
to guide treatment. Case formulations should also provide a framework
for monitoring the clinical status of patients over the course of treatment,
as suggested for psychodynamic and cognitive-behavioral case formula-
tions (Semple and Smyth, 2013). Third, recognizing that interrater agree-
ment in ratings for the SCF case formulation was found to be low for the
CFI, training strategies are needed to enhance its reliable use, especially
for structural detail.
Regular and consistent use of the CFI as an intake instrument for
assessment was among the goals driving its development. Brevity was
important, and a CFI interview is expected to take only about 20 minutes
because “practical concerns were front and center.”The CFI handbook
elaborates on that: “To be taken up widely, interventions must be feasi-
ble and cost-effective, or they risk remaining of academic interest only”
(Lewis-Fernández et al., 2016). An exclusive priority of regular use as
an intake assessment, however, limits the value of the CFI for the kind
of mini-ethnography suggested by Kleinman and Benson (2006) and
for in-depth case studies desired by Rousseau et al. (2020).
In our study, focusing on relatively more in-depth case formula-
tions, CFI and SCFI interviews both averaged over an hour. It is un-
likely that instruments for SCF, neither CFI nor SCFI, will be used that
way in routine practice. Consistent use of even a 20-minute intake inter-
view in routine practice may be unlikely. It is likely, however, and both
desirable and feasible, that training and strategic use of the CFI in train-
ing and practice will help clinicians to assess patients and construct SCF
case formulations in their practice both to guide treatment and as a
framework for monitoring clinical status over the course of treatment.
Although the CFI may be helpful for that, clinicians' internalization
and use of the framework of SCF case formulation, which we have stud-
ied, are more important. As with DSM diagnoses, mastering and inter-
nalizing the concepts are more important than whether a clinician is
using a particular assessment instrument for that.
Significance and Implications
Both the CFI and SCFI assessment instruments provided valued
case data for SCF case formulations based on principles of cultural psy-
chiatry and structural competency, which itself is rooted in principles of
social medicine (Braslow and Bourgois, 2019). Our findings suggest
several timely and important points for further consideration:
1. As the values of psychiatry, both cultural and mainstream, converge
with priorities of social medicine, replacing a cultural formulation
based on the OCF with case formulation based on the SCFwould en-
hance that process of convergence more explicitly and effectively.
2. After publication of the OCF in DSM-IV, the literature on cultural
formulation prioritized formulation content in case reports. After
publication of the CFI inthe DSM-5, the literature on cultural formu-
lation prioritized formulation process, as it advocated routine use of
the CFI. Balancing these respective priorities should be goals of
training and routine use of sociocultural case formulations.
3. Extensive use of the OCF for case formulations in diverse settings,
experience in multicenter field trials of the CFI, and use of both
for training in cultural psychiatry have facilitated the current accep-
tance and high regard for the OCF and CFI. Similarly, case reports
and training programs have enhanced appreciation of structural com-
petency. Use of the SCF framework to harmonize cultural and structural
prioritieswould benefit from further clinical experience and research
like ours in other settings, not only in India but also in other coun-
tries. Our study therefore provides empirical justification and a guide
for such work to proceed.
Response to Skeptics
Our proposition to update the approach to case formulation in
cultural psychiatry based on our research findings is more timely than
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radical. Some may disagree, or like Groen and Drožđek (2022), they
may favor alternative approaches. We therefore consider and comment
on several potential points of reluctance to rethink a cultural formula-
tion as sociocultural, and to integrate benefits of process and content
as complementary interests in case formulation:
Objection 1: The OCF is adequate in its present form, and there
is no need for further revision because the current structure remains
good enough.
Although we have criticizedthe third domain of the OCF for fail-
ing to acknowledge and distinguish structural vis-à-vis social interper-
sonal issues, some may argue that the third domain of the OCF is suffi-
ciently broad to accommodate structural issues, and the distinction does
not need to be made more explicit. That argument, however, ignores se-
rious criticism of cultural competency from the vantage point of struc-
tural competency, and it appears to ignore the impact of structural prior-
ities of social medicine that are concerns of many patients. Disregarding
such issueswidens the gap between cultural psychiatry and social med-
icine, and it invites further criticism of psychiatry as unresponsive to
structural challenges.
Objection 2: Highlighting structural issues imposes responsibil-
ities on mental health care providers beyond their training and capacity
to respond.
A patient-centered case formulation is obligated to provide pa-
tients an opportunity to recount relevant experience. Both empathic lis-
tening andefforts toameliorate the structural burden are valued. The ca-
pacity for identifying relevant structural issues, ways of responding—
both directly and indirectly through informed advocacy—and humility
in distinguishing what can and cannot be done about social determinants
are among the benchmark skills of structural competency training. Al-
though it is difficult and frustrating to ask about issues that clinicians
cannot remedy, failure to ask, to listen, and to acknowledge imposes
an additional burden.
By ignoring structural contributions to the illness burden, clini-
cians may also become unwittingly complicit with cultural and struc-
tural violence, and they miss opportunities to apply, improve, and inno-
vate clinical skills and resources of a treatment team in settings where
structural issues require clinical acknowledgement and attention
(Ballo and Tribe, 2023). Even that acknowledgement of what can and
cannot be done is itself helpful. Clinicians, in particular, may be
regarded as derelict if they do not do that much, inasmuch as liberating
people from the “concrete situations”in which they find themselves is a
matter that “concerns the whole of humanity”(Fanon, 1967, p. 144).
Objection 3: The CFI with its demonstrated value of interview
process is fine; no need for further organization of assessment findings
in a case formulation based on either the SCF or the OCF.
A stated purpose of the CFI had been to provide a tool and tech-
nique for case formulations based on the OCF framework. Paradoxically,
however, it seems fewer cultural formulation case reports have been pub-
lished after development of the CFI than before. The initial motivation
has become an afterthought. Case studies in social medicine and the lit-
erature of structural competency show the value of case reports for clin-
ical communications and training. Cautioning about the pitfalls of over-
emphasizing methodological process without sufficient attention to the
purpose of the methods, Rollo May's sage advice 65 years ago remains
relevant: “In our preoccupation with technique, laudable enough in itself,
we tend to overlook the fact that technique emphasized by itself in the
long run defeats even technique”(May, 1958, p. 10).
CONCLUSION
This study responded to neglected priorities of social medicine in
a formulation of cultural psychiatry developed more than four decades
ago, which had positioned the field in the space between anthropology
and psychiatry, based on a view of social science that was more attentive
to cultural than social determinants of health. The cultural formulation,
the OCF, and the CFI, which were rooted in that cultural psychiatry,
have nevertheless made major contributions to training, practice, and
research, and their inclusion in the DSM has contributed to awareness
of the relevance of culture and social science in general psychiatry.
Our study explains the rationale, based on empirical data, for updating
the OCF as SCF as a framework for case formulation to harmonize pri-
orities of cultural psychiatry and social medicine, and skills of cultural
and structural competency.
Our study also highlights the complementary benefits of case
formulation derived from both the content of case data and the process
of sharing experience inan empathic, patient-centered assessment. This
sociocultural framework for psychiatric case formulation should con-
tribute to training and clinical care—not just for intake assessment but
as an internalized framework for practice that includes status updates over
the course of treatment. It should be useful for documentation, profes-
sional communications, and research. Like the OCF, the SCF is intended
not to replace, but to complement, a diagnostic formulation. Achieving
these goals is a work in progress, and further clinical experience and re-
search in other settings will hopefully contribute.
ACKNOWLEDGEMENT
We gratefully acknowledge funding and administrative support of
the KEM Hospital Research Centre, Pune, India. The research team in-
cluded Aarti Subandh, project coordinator; she and Shachi Kashikar
managed research data and participated in analysis. SK and Pranita
Date conducted interviews and were internal evaluators. Srushti Parkhi
and Sakshi Katariya assisted and participated in regular project meet-
ings. External evaluators included psychologist Dr Nishreen Saif and
psychiatrists Dr Sharmishtha Deshpande, Dr Arvind Panchanadikar,
Dr Kishor Jadhavar, Dr Amit Nulkar, Dr Suchita Agrawal, Dr Rishikesh
Behere, Dr Vidya Ganapathy, and Dr Jyoti Shetty. The late Professor
Vaishali Naik prepared Hindi and Marathi translations of the research
instruments (CFI and SCFI). We also gratefully acknowledge patients
who consented to participate in the study.
DISCLOSURE
Conflicts of interest and funding source: The authors have no con-
flict of interest to declare.
The KEM Hospital Research Centre provided funds and adminis-
trative support to the project.
The study was conducted according to acceptable research stan-
dards, and informed consent was obtained from all study patients. The
study was reviewed and approved by the KEM Hospital Research Centre
Ethics Committee and approved on July 9, 2020 (Ref: KEMHRC/RVM/
EC/535).
Attestation of contributions: All authors have read and approved
the submitted manuscript, and they agree to be accountable for all as-
pects of the work. Each author qualifies for authorship based onICMJE
guidelines by having made a substantive intellectual contribution to the
development of the manuscript with reference to their particular contri-
butions: M. G. W. contributed to the conception; design; analysis and
interpretation of data; and drafting and revision of the submitted man-
uscript. A. D. contributed to the conception; design; acquisition, anal-
ysis, and interpretation of data; and drafting and revision of the submit-
ted manuscript. S. B. S. contributed to the analysis and interpretation of
data presented in the submitted manuscript. V. P. P. contributed to the
conception; design; acquisition, analysis, and interpretation of data;
and drafting and revision of the submitted manuscript.
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