DSM-5® Handbook On The Cultural Formulation Interview

®
DSM-5
Handbook on the
Cultural Formulation
Interview
This page intentionally left blank
®
DSM-5
Handbook on the
Interview
Edited by
Roberto Lewis-Fernández, M.D., M.T.S.

Neil Krishan Aggarwal, M.D., M.B.A., M.A.
Ladson Hinton, M.D.
Devon E. Hinton, M.D., Ph.D.
Laurence J. Kirmayer, M.D.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accu-
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Library of Congress Cataloging-in-Publication Data
DSM-5® handbook on the cultural formulation interview / edited by Roberto Lewis-
Fernández, Neil Krishan Aggarwal, Ladson Hinton, Devon E. Hinton, Laurence J.
Kirmayer. — First edition.
p. ; cm.
Handbook on the cultural formulation interview
Includes bibliographical references and index.
ISBN 978-1-58562-492-8 (pbk. : alk. paper)
I. Lewis-Fernández, Roberto, 1958- , editor. II. Aggarwal, Neil Krishan, editor. III.
Hinton, Ladson, 1958- , editor. IV. Hinton, Devon E., editor. V. Kirmayer, Laurence J.,
1952- , editor. VI. American Psychiatric Association, issuing body. VII. Title: Hand-
book on the cultural formulation interview.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Inter-
view, Psychological—methods. 3. Culturally Competent Care—methods. 4. Ethno-
psychology—methods. 5. Mental Disorders—ethnology. WM 143]
RC467
616.89—dc23
2015007125
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Arthur Kleinman, M.D.
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxi
Video Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
1 Cultural Formulation Before DSM-5 . . . . . . . . . . . . . 1

2 The Core and Informant Cultural Formulation

Interviews in DSM-5 . . . . . . . . . . . . . . . . . . . . . . . . . 27
Oscar Jiménez-Solomon, M.P.H.
Peter C. Lam, M.P.H.
Ladson Hinton, M.D.
3 Supplementary Modules . . . . . . . . . . . . . . . . . . . . . .45
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Ladson Hinton, M.D.
Supplementary Module 1:
Explanatory Model. . . . . . . . . . . . . . . . . . . . . . . . 56
Mitchell G. Weiss, M.D., Ph.D.
Level of Functioning . . . . . . . . . . . . . . . . . . . . . . 68
Smita Neelkanth Deshpande, M.D., D.P.M.
Triptish Bhatia, Ph.D.
Vishwajit Laxmikant Nimgaonkar, M.D., Ph.D.
Sofie Bäärnhielm, M.D., Ph.D.
Social Network. . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Esperanza Díaz, M.D.
Tichianaa Armah, M.D.
Ladson Hinton, M.D.
Psychosocial Stressors . . . . . . . . . . . . . . . . . . . . 81
Adil Qureshi, Ph.D.
Irene Falgàs, M.D.
Francisco Collazos, M.D.
Ladson Hinton, M.D.
Spirituality, Religion, and Moral Traditions . . . . . 90
David M. Gellerman, M.D., Ph. D.
Francis G. Lu, M.D.
Cultural Identity . . . . . . . . . . . . . . . . . . . . . . . . . 101
Aspects of Cultural Identity Related to
National, Ethnic, and Racial Background;
Language; and Migration . . . . . . . . . . . . . . . . . .107
Simon Groen, M.A.
Hans Rohlof, M.D.
Sushrut Jadhav, M.B.B.S., M.D., MRCPsych, Ph.D.
Aspects of Cultural Identity Related to
Spirituality, Religion, and Moral Traditions . . . .118
David M. Gellerman, M.D., Ph.D.
Francis G. Lu, M.D.
Aspects of Cultural Identity Related to Gender
Identity and Sexual Orientation Identity . . . . . .123
John E. Pachankis, Ph.D.
Mark L. Hatzenbuehler, Ph.D.
Coping and Help Seeking . . . . . . . . . . . . . . . . .136
Martin La Roche, Ph.D.
Patient-Clinician Relationship . . . . . . . . . . . . . .145
Hans Rohlof, M.D.
Rob van Dijk, M.Sc.
School-Age Children and Adolescents . . . . . . .156
Cécile Rousseau, M.D.
Jaswant Guzder, M.D.

Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . .165
Ladson Hinton, M.D.

Immigrants and Refugees . . . . . . . . . . . . . . . . .173
James Boehnlein, M.D., M.Sc.
Joseph Westermeyer, M.D., Ph.D.
Monica Scalco, M.D., Ph.D.
Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Ladson Hinton, M.D.
Rita Hargrave, M.D.
Iqbal Ahmed, M.D.
4 Clinical Implementation of
the Cultural Formulation Interview. . . . . . . . . . . . .191
Planning and Assessment . . . . . . . . . . . . . . . . . 191
Use of the Cultural Formulation

Interview in Different Clinical Settings . . . . . . . 208
Renato D. Alarcón, M.D., M.P.H.
Johann Vega-Dienstmaier, M.D.
Lizardo Cruzado, M.D.
Administrative Perspectives on the

Implementation and Use of the
Cultural Formulation Interview . . . . . . . . . . . . . 224
Kavoos Ghane Bassiri, M.S., LMFT, LPCC, CGP
Angela Tang Soriano, M.S.S.W., LCSW
Application of the Cultural Formulation

Interview in International Settings . . . . . . . . . . 237
David M. Ndetei, M.B.Ch.B., D.P.M., MRCPsych, FRCPsych, M.D., D.Sc.
Hans Rohlof, M.D.
K. Musa Misiani, B.Sc. Hons
Victoria M. Mutiso, M.Sc., Ph.D.
Abednego M. Musau, M.B.Ch.B.
Rhodah Mwangi, B.A.
5 Cultural Competence in Psychiatric Education

Using the Cultural Formulation Interview . . . . . . .253
Russell F. Lim, M.D., M.Ed.
Hendry Ton, M.D., M.S.
6 Conclusion:
The Future of Cultural Formulation. . . . . . . . . . . . 267
Appendix A
Cultural Formulation Interview (CFI)–Core
Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Appendix B
Cultural Formulation Interview (CFI)–Informant
Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Appendix C
Supplementary Modules to the Core Cultural
Formulation Interview (CFI) . . . . . . . . . . . . . . . . . . 299
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Contributors
Assistant Professor of Clinical Psychiatry, Columbia University; Research Psychiatrist,
New York State Psychiatric Institute, New York, New York
Iqbal Ahmed, M.D.

Faculty Psychiatrist, Tripler Army Medical Center, Honolulu, Hawaii; Clinical Profes-
sor of Psychiatry, Uniformed Services University for Health Sciences, Bethesda, Mary-
land; Clinical Professor of Psychiatry and Geriatric Medicine, University of Hawaii,
Honolulu, Hawaii

Emeritus Professor of Psychiatry, Mayo Clinic College of Medicine, Rochester, Min-
nesota; Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Peru

Assistant Clinical Professor of Psychiatry, Yale University School of Medicine, New
Haven, Connecticut

Consultant Psychiatrist and Director, Transcultural Centre, Stockholm County
Council, Stockholm, Sweden

President and Chief Executive Officer, Richmond Area Multi-Services; Associate
Clinical Professor, Department of Psychiatry, University of California San Francisco
School of Medicine, San Francisco, California

Chief Investigator, Global Research Initiative Program, National Institutes of Health
(USA); Department of Psychiatry, Post-Graduate Institute of Medical Education and
Research—Dr. Ram Manohar Lohia Hospital, New Delhi, India

Professor of Psychiatry, Oregon Health & Science University, Portland, Oregon
xi
xii DSM-5 Handbook on the Cultural Formulation Interview

Adjunct Professor of Psychiatry and Legal Medicine, Universitat Autònoma de Bar-
celona; Staff Psychiatrist, Servei de Psiquiatria, Hospital Universitari Vall d’Hebron,
Barcelona, Spain

Instructor in Psychiatry, Universidad Peruana Cayetano Heredia; Staff Psychiatrist,
Instituto Nacional de Salud Mental “Honorio Delgado-Hideyo Noguchi,” Lima, Peru

Consultant, Professor, and Head, Department of Psychiatry and De-addiction Ser-
vices, Post-Graduate Institute of Medical Education and Research—Dr. Ram Manohar
Lohia Hospital, New Delhi, India
Ravi DeSilva, M.D., M.A.

Associate Director of Inpatient Psychiatry, Milstein Hospital, Columbia University
Medical Center, New York, New York.

Associate Professor of Psychiatry, Yale University School of Medicine, New Haven,
Connecticut
Irene Falgàs, M.D.

Researcher, Vall d’Hebron Institut de Recerca; Psychiatrist, Servei de Psiquiatria,
Hospital Universitari Vall d’Hebron, CIBERSAM, Barcelona, Spain

Assistant Clinical Professor of Psychiatry, University of California Davis School of
Medicine, Sacramento; Staff Psychiatrist, VA Northern California Health Care Sys-
tem, Mather, California
Simon Groen, M.A.

Cultural Anthropologist, De Evenaar, Centre for Transcultural Psychiatry, GGZ
Mental Health Care, Beilen, The Netherlands

Associate Professor, Department of Psychiatry, McGill University; Head of Child
Psychiatry, Jewish General Hospital Institute of Community and Family Psychiatry,
Montreal, Quebec, Canada
Rita Hargrave, M.D.

Clinical Instructor, University of California Davis School of Medicine, Sacramento,
California
Contributors xiii

Assistant Professor of Sociomedical Sciences, Mailman School of Public Health,
Columbia University, New York, New York

Associate Professor of Psychiatry, Massachusetts General Hospital, Harvard Medical
School, Boston, Massachusetts
Ladson Hinton, M.D.

Professor of Psychiatry, University of California Davis School of Medicine, Sacra-
mento, California

Senior Lecturer in Cross-Cultural Psychiatry, University College London, London,
United Kingdom

Research Coordinator, New York State Center of Excellence for Cultural Competence,
New York State Psychiatric Institute, New York, New York

James McGill Professor and Director, Division of Social and Transcultural Psychiatry,
McGill University, Montreal, Quebec, Canada

Esther and Sidney Rabb Professor of Anthropology, Department of Anthropology,
Harvard University; Professor of Medical Anthropology and Professor of Psychia-
try, Department of Global Health and Social Medicine, Harvard Medical School;
Victor and William Fung Director, Harvard University Asia Center, Cambridge,
Massachusetts

Data Analyst, New York State Center of Excellence for Cultural Competence, New
York State Psychiatric Institute, New York, New York

Assistant Professor of Psychology, Department of Psychiatry, Boston Children’s
Hospital/Harvard Medical School, Boston, Massachusetts

Professor of Psychiatry, Columbia University Medical Center; Director, New York
State Center of Excellence for Cultural Competence and Hispanic Treatment Program,
New York State Psychiatric Institute, New York, New York; Lecturer, Department of
Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
xiv DSM-5 Handbook on the Cultural Formulation Interview

Health Sciences Clinical Professor of Psychiatry and Director of Diversity Educa-
tion and Training, University of California Davis School of Medicine, Sacramento,
California
Francis G. Lu, M.D.

Luke and Grace Kim Professor in Cultural Psychiatry, Emeritus, University of Cali-
fornia Davis School of Medicine, Sacramento, California

Medical Student, University of Nairobi, and Research Associate, Africa Mental
Health Foundation, Nairobi, Kenya

Researcher, Africa Mental Health Foundation, Nairobi, Kenya

Research Director, Africa Mental Health Foundation, Nairobi, Kenya
Rhodah Mwangi, B.A.

Communications Officer, Africa Mental Health Foundation, Nairobi, Kenya

Professor of Psychiatry, University of Nairobi, and Founding Director, Africa Mental
Health Foundation, Nairobi, Kenya

Professor of Psychiatry and Human Genetics, Departments of Psychiatry and Human
Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania

Associate Professor of Epidemiology, Yale School of Public Health, New Haven,
Connecticut
Adil Qureshi, Ph.D.

Psychologist, Servei de Psiquiatria, Hospital Universitari Vall d’Hebron; Adjunct
Professor, Institute for the International Education of Students, Barcelona, Spain
Hans Rohlof, M.D.

Clinical Psychiatrist and Researcher, Head of the Outpatient Refugee Clinic, Centrum
’45, Oegstgeest, The Netherlands

Professor, Division of Social and Cultural Psychiatry, Department of Psychiatry, Mc-
Gill University, Montreal, Quebec, Canada
Contributors xv

Assistant Professor of Psychiatry, University of Toronto, Toronto, Ontario, Canada

Director of Operations, Richmond Area Multi-Services, San Francisco, California
Rob van Dijk, M.Sc.

Medical Anthropologist, Parnassia Academy, Parnassia Psychiatric Institute, The
Hague, The Netherlands

Health Sciences Associate Clinical Professor, Director of Medical Student Education
in Psychiatry, Director of Cultural Competency and Professionalism, and Director of
Education at the Center for Reducing Health Disparities, Department of Psychiatry
and Behavioral Sciences, University of California Davis School of Medicine; Medical
Director, Transcultural Wellness Center, Sacramento, California

Assistant Professor of Psychiatry, Universidad Peruana Cayetano Heredia; Staff Psy-
chiatrist, Hospital Nacional Cayetano Heredia, Lima, Peru

Professor, Department of Epidemiology and Public Health, Swiss Tropical and Public
Health Institute, and University of Basel, Basel, Switzerland

Professor of Psychiatry, University of Minnesota; Staff Physician, Minneapolis VA
Health Care Center, Minneapolis, Minnesota
Disclosure of Competing Interests

The following contributors to this book have indicated a financial interest in or other affiliation
with a commercial supporter, a manufacturer of a commercial product, a provider of a commer-
cial service, a nongovernmental organization, and /or a government agency, as listed below:
Iqbal Ahmed, M.D.—Chief Editor and formerly Managing Editor for Psychiatry
section for eMedicine, Medscape, an online Internet textbook of medicine, 2001 to
present
Roberto Lewis-Fernández, M.D.—Research support: Principal Investigator of an

investigator-initiated study with Eli Lilly
Russell Lim, M.D.—Book royalties: Clinical Manual of Cultural Psychiatry, APPI, 2014
xvi DSM-5 Handbook on the Cultural Formulation Interview
The following contributors to this book have indicated no competing interests to disclose dur-
ing the year preceding manuscript submission:

Simon Groen, M.A.
Rita Hargrave, M.D.
Mark L. Hatzenbuehler, Ph.D
Ladson Hinton, M.D.
Laurence J. Kirmayer, M.D., FRCPC
Francis G. Lu, M.D.
Rhodah Mwangi, B.A.
Adil Qureshi, Ph.D.
Hans Rohlof, M.D.
Rob van Dijk, M.Sc.
Foreword
In the 1970s, when I began my research and writing, cultural psychiatry as

a field was principally concerned with epidemiological and clinical studies of dis-
eases that were either common or uncommon in Europe and America (Kleinman
1978; Kleinman et al. 1978). The leading questions turned on whether the common
diseases differed in symptomatology or prevalence in the non-Western world and
among members of minorities in the West, and what kind of conditions the uncom-
mon diseases were. When mental health services were considered, and often they
were not because they were so thin on the ground then, the chief issues were why
people from different racial, ethnic, and cultural groups failed to access psychiatric
services or why those who were in treatment did not comply.
My generation of cultural psychiatrists and psychiatric anthropologists decisively
shifted the central concerns in another direction. We asked research questions about
the ideas that patients and family members held concerning sickness and treatment,
and we compared those ideas with those held by practitioners, who also could be un-
derstood as participating in cultures (both professional and personal). My own con-
tributions were to set out a method to elicit patient, family, and practitioner models
of illness and treatment experiences (explanatory models) and to understand them as
representative of local moral worlds in which culture, among other things, shaped what
was at stake for individuals and in relationships. I also introduced the notion of the cat-
egory fallacy, which resulted from the application of professional biomedical catego-
ries in places where those categories had no local cultural significance but instead
imposed an alien ideology on indigenous illness experiences and treatment practices,
thereby distorting both. I was interested in using these ideas to help understand clin-
ical reality (what practices were at stake for clinicians in particular health care insti-
tutions) and the patient-doctor relationship as social processes shaped by cultural,
political, economic, institutional, and other social forces.
I attempted to introduce these ideas into clinical practice, not only in psychiatry
but also in internal medicine and family medicine, through a National Institute of
Mental Health–funded clinical anthropology predoctoral and postdoctoral training
program (organized with Byron Good and Mary-Jo Good), M.D.-Ph.D. and master’s-
level programs, clinical rounds at the University of Washington Medical Center, Seat-
tle, and Cambridge Hospital in Cambridge, Massachusetts, and many presentations
and publications. Four of the editors of this important volume (Roberto Lewis-
Fernández, Neil Aggarwal, Ladson Hinton, and Devon Hinton) were my former stu-
dents. Mitchell Weiss, another former trainee, developed a more systematic measure
of explanatory models that facilitated matters. They, along with other contributors,
have moved this field forward significantly by developing the cultural formulation
xvii
xviii DSM-5 Handbook on the Cultural Formulation Interview
approach, which I regard as the single most practically useful contribution of cultural
psychiatry and medical anthropology to clinical work in psychiatry and, because this
approach is also relevant, in primary care and medicine generally.
A little additional background information is needed to clarify the substantial ad-
vance that this volume represents. I cochaired the Task Force on Culture for DSM-IV.
That group developed many cultural materials, of which very few were included in
DSM. An earlier version of the cultural formulation was outlined in Appendix I, the
ninth appendix, in DSM-IV (American Psychiatric Association 1994). It was little
more than a template, the details of which were left for clinicians to fill in and de-
velop.
Over the years, a number of clinical researchers around the world, including es-
pecially the editors of this book, developed the cultural formulation into the detailed,
evidence-based, and clinically useful interview methodology detailed in this volume.
The chapters on the cultural formulation before DSM-5 (American Psychiatric Asso-
ciation 2013) (Chapter 1), on the core and informant versions of the Cultural Formu-
lation Interview (CFI) (Chapter 2), and on implementation (Chapter 4) disclose the
very substantial research that has gone into establishing the CFI as an implementable
best practices approach that can be systematically taught and applied in the field,
evaluated, assembled into an implementation package, and scaled up. This is an im-
pressive achievement, and one that holds the promise of becoming truly influential
in clinical settings. Looking back over the 40 years since I introduced the explanatory
model approach in the academic literature, it is shocking but also inspiring to see how
far this field of clinically applied studies has come.
Although I enthusiastically applaud the achievement, I also recognize the impor-
tance of considering the cultural formulation’s potential limits and also its potential,
like all interventions, for unintended consequences. After I introduced the explana-
tory model approach, for example, I received many invitations from medical schools
and hospitals to visit, deliver grand rounds or a named lecture, and meet with resi-
dents, students, and faculty. The purpose was usually to use my presence to focus on
cultural issues of salience in medicine. On teaching rounds with inpatients during
these visits, I was regaled with accounts of explanatory models—one patient, one
model—as if they were fixed in time and materialized like other clinical “substances”:
electrolytes, hematocrit, and so forth. This entification of meaning produced exactly
the opposite effect from the one the explanatory models approach was meant to
achieve. Instead of opening conversations between patients and physicians, it
stopped them. In other words, explanatory models were appropriated by powerful
biomedical structures—cognitive, institutional, and cultural—in such a way as to un-
dermine their value. I hope the same thing does not happen with the cultural formu-
lation, but I think we should be prepared that such an unintended consequence could
occur. To my mind, the greatest danger for all cultural interventions is that they will
end up stereotyping patients and families with biased and superficial representations
that will meet regulatory requirements, and therefore be seen as bureaucratically use-
ful, yet only bring greater misunderstanding and stigma into the clinical relationship.
How to prevent this from happening is the question that the contributors to and read-
ers of this book will need to think hard about (Kleinman 1988, 1995). The fact that the
Foreword xix
Explanatory Model supplementary module explicitly asks patients about changes in

explanatory models throughout the illness experience is a step in a better direction
(see supplementary modules in Appendix C in this handbook).
My suggestion is that the cultural formulation be taught and used with two ex-
plicit sensitivities in mind: first, a recognition that medicine itself is a particular cul-
tural reality whose influence must be accounted for and, second, an awareness of the
outcome of the CFI, assessing what, in any given case, it has accomplished and in-
cluding a systematic checklist to rule out introduction of stereotypes. The exemplary
chapter on the field testing of core and informant versions of the CFI (Chapter 2, “The
Core and Informant Cultural Formulation Interviews in DSM-5”) demonstrates that
there are various measures of successful application and that, properly used, the CFI
need not contribute to the problem of stereotyping, although it remains for me a con-
cern. Applied with these two sensitivities taken into account, the CFI has great prom-
ise. Hence I see this volume as a major step forward in making the contributions of
cultural psychiatry and medical anthropology available in the clinic.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
4th Edition. Washington, DC, American Psychiatric Association, 1994
5th Edition. Arlington, VA, American Psychiatric Association, 2013
Kleinman A: Concepts and a model for the comparison of medical systems as cultural systems.
Soc Sci Med 12(2B):85–95, 1978 358402
Kleinman A: Rethinking Psychiatry. New York, Free Press, 1988
Kleinman A: Introduction, in Writing at the Margin. Berkeley, University of California Press,
1995, pp 1–18
Kleinman A, Eisenberg L, Good B: Culture, illness, and care: clinical lessons from anthropolog-
ical and cross-cultural research. Ann lntern Med 88:251–258, 1978
Preface
This handbook on how to conduct a cultural assessment using the DSM-5

(American Psychiatric Association 2013) Cultural Formulation Interview (CFI) is di-
rected at clinicians, administrators, policy makers, advocates, and other practitioners
who work together to engage patients in the delivery of mental health care. We aim
to make it easier for providers to account for the influence of culture in their work, in
order to enhance patient-clinician communication in all clinical encounters—not only
among participants judged to be culturally different—and improve outcomes of care.
Accordingly, our primary audience is the clinician in mental health practice, of any
discipline, who evaluates and negotiates treatments with patients on a regular basis.
However, other stakeholders in care, including patients, will find guidance in these
chapters, especially in the descriptions of the elements of culture—including the cul-
ture of mental health practice—that shape for all of us our understandings of illness,
experiences of distress, and expectations and concerns about care, whether we are po-
sitioned as clinicians or as patients in any given clinical encounter.
The CFI and this book are the products of the work of many people over the last
two decades, particularly since the publication of DSM-IV (American Psychiatric As-
sociation 1994). Published in DSM-5 in 2013, the CFI emerged from efforts, especially
in North America and Europe, to develop questionnaires, interview protocols, and
semistructured instruments to help clinicians obtain the information that the DSM-
IV Outline for Cultural Formulation described as basic to cultural assessment. Many
of the authors of these pre-CFI assessment tools were members of the DSM-5 Cross-
Cultural Issues Subgroup, which led the CFI development process from 2007 to
2013. Many others participated in the DSM-5 international field trial that tested the
feasibility, acceptability, and perceived clinical utility of one of the three CFI compo-
nents, the 16-item core CFI, for use in daily mental health practice (note usage of CFI
to indicate multiple components and core CFI to indicate the 16-question interview).
Still others contributed their extensive clinical-cultural expertise to summarize for
clinicians the elements of cultural assessment that guided the development of each
CFI component and module. This handbook, and indeed the CFI itself, would not
be possible without their work.
In this handbook, we describe and illustrate the use of the core CFI, the CFI–
Informant Version for obtaining collateral information, and the 12 supplementary
modules that expand on these basic assessments. The chapters include case vi-
gnettes, and video commentaries flesh out the use of these components. (The videos
may be viewed at www.appi.org/Lewis-Fernandez. See also “Video Guide” in the
handbook.) We also devote considerable attention to the issues of how to implement
the CFI in contemporary practice—including its application in different clinical set-
xxi
xxii DSM-5 Handbook on the Cultural Formulation Interview
tings (e.g., inpatient units, emergency departments) and in diverse international

contexts—and how to train clinicians at all stages of professional development in its
use. Further work is ongoing, in many parts of the world, to disseminate the CFI, fa-
cilitate and test its implementation, train practitioners, and examine its effectiveness.
Feedback can be provided at www.dsm5.org/Pages/Feedback-Form.aspx. An on-
line training video developed by the New York State Office of Mental Health will
also be available in the near future to encourage implementation of the CFI in public
mental health systems. Information on this video will be available at the Web site of
the New York State Center of Excellence for Cultural Competence at New York State
Psychiatric Institute: www.nyspi.org/culturalcompetence. Our hope is that these
multiple efforts will result in a maximally effective CFI that can be widely applied
and can help enhance clinical care.

September 26, 2014
References
Video Guide
The Video Learning Experience
The videos can be viewed online at www.appi.org/Lewis-Fernandez.
To illustrate use of the Cultural Formulation Interview (CFI), the DSM-5® Handbook
on the Cultural Formulation Interview includes access to a video with segments of a
complete core CFI titled Full CFI in addition to 17 videos that demonstrate the appli-
cation of portions of the core CFI and several supplementary modules. Pertinent vid-
eos are highlighted and described in selected, content-related chapters. Viewers may
note that some of the filmed interviews are meant to demonstrate use of the semis-
tructured questions in a short period of time; although these tend not to deviate from
the recommended wording, users may choose instead to tailor the questions to their
clinical situation, for example, by using only selected questions, altering the wording
while adhering to the intent of the question, and interspersing more expressions of
empathy or statements intended to evoke further elaboration of the interview topics.
Viewers may also note that the videos feature clinicians with various degrees of ex-
perience using the CFI; some have memorized it, whereas others read questions
aloud. This variation is deliberate, intended to portray clinicians in natural practice
settings and to avoid the impression that all CFI questions must be memorized prior
to use. The theme uniting all videos is the clinician’s commitment to discovering the
patient’s interpretations of the illness experience.
Using the Book and the Videos Together

We recommend that readers use the boldface video prompts embedded in the text
as signals for viewing the associated clips in the online viewer at www.appi.org/
Lewis-Fernandez. The cues identify the vignettes by title and run time. (The videos
are optimized for most current operating systems, including mobile operating sys-
tems iOS 5.1 and Android 4.1 and higher.)
Descriptions of the Videos

Video 1: Full CFI (6:57)
The relationship between the individual and her social network is on display, illus-
trating use of the core CFI, which includes segments of a full CFI evaluation.
xxiii
xxiv DSM-5 Handbook on the Cultural Formulation Interview
Video 2: What does that have to do with my lungs? (4:26)

The consultation aims to elucidate the patient's interpretations of her illness and of
her caregivers' behavior to understand her objections to recommended treatment.
Video 3: They get outta whack sometimes (2:19)

Several aspects of the patient’s explanatory model are explored.
Video 4: If it’s not one thing, it’s another (3:46)

As the interview progresses, the patient begins to disclose the stressors associated
with her condition and the role her social network plays in how she views her condi-
tion.
Video 5: DWI (3:46)

Using the CFI supplementary module on level of functioning to assess how a pa-
tient’s drinking problem affects his work, earnings, life goals, and relationships is il-
lustrated.
Video 6: The family (2:35)

The clinician conducts the core CFI with a woman with postpartum depression, ex-
ploring the important role that the patient’s family members play in her social net-
work.
Video 7: Bridging the gap (3:57)

Through use of the core CFI, the patient’s preferences for care, which include reflect-
ing on the role of his faith in treatment and asking what kinds of help would be most
beneficial considering his faith and values, are ascertained.
Video 8: Crisis of faith (3:54)

The supplementary module Spirituality, Religion, and Moral Traditions is used to
elicit faith-related elements of support and conflict for a young man in the emergency
department who is struggling with thoughts of suicide.
Video 9: A small town, which is why I’m here (4:39)

A psychiatrist conducts an interview with a patient whose symptoms of anxiety are
best understood within the framework of his migration experience and his cultural
expectations.
Video Guide xxv
Video 10: It gets kind of confusing (2:41)

The interview illustrates some of the complexities of identity that may affect a patient’s
clinical presentation. Knowledge about her cultural identity is essential for treatment.
Video 11: You still show up on Sunday (3:26)

The patient’s answers to core CFI questions reveal important values as well as conflicts
about his sense of himself that stem from the role of spirituality and religion in his life.
Video 12: Ties that bind (3:35)

The clinician’s prompts elicit the patient’s description of feelings of anger and social
isolation and her conflictive family situation in relation to the disclosure of her sexual
orientation identity.
Video 13: I don’t have a problem (3:00)

Through the interview, the patient’s various coping strategies are revealed.
Video 14: Planning for something better (1:59)

Using the core CFI, the clinician explores the patient’s expectations and perceived
barriers to treatment, and the patient explains what could help her more effectively.
Video 15: In my own language (0:42)

How the core CFI question on the patient-clinician relationship can yield useful concrete
information to guide treatment planning even during an intake visit is demonstrated.
Video 16: After the fall (4:00)

Questions from the supplementary module Older Adults highlight how develop-
mental experiences around aging are a source of dynamic cultural meaning-making
during an illness.
Video 17: Getting back on my feet (3:46)

The interviewer transitions to the domain of the supplementary module on the qual-
ity and nature of social supports and caregiving by asking how recovery has changed
relationships with friends and family.
Video 18: I’ve been feeling really frustrated (4:20)

The interview shows how the core CFI functions well in a situation of acute symptom-
atology in the emergency department.
xxvi DSM-5 Handbook on the Cultural Formulation Interview
Video Credits
The senior video content and production editor was Ravi DeSilva M.D., M.A. The
video examples of CFI interviews created for this book were developed and pro-
duced by a core interdisciplinary team of physicians and social workers committed
to improving cultural competence training and education for all clinicians. The CFI
video writing, production, and editing team consisted of Ravi DeSilva M.D., M.A.;
Matthew Pieh M.D.; Courtney Flint, LMSW; Linda Gregory, LMSW; and Carlos
Benítez, M.S.W.
Special thanks go to the cast of these films who generously gave their time and tal-
ents to bring these scenarios to life, highlighting the many ways in which culture im-
pacts clinical care. The video cast members are Neil Krishan Aggarwal, Cándida C.
Batista, Carlos Benítez, Enrico Castillo, Ravi DeSilva, Bruce Dohrenwend, Courtney
Flint, Linda Gregory, Sheldene Gorovitzc, Myunghoon Kim, Roberto Lewis-Fernán-
dez, Lee Lovejoy, Hamna Mela, Matthew Pieh, Paul Reardon, and Lianna Valdez.
Note. The clinical cases portrayed are fictional. Any resemblance to real persons is
purely coincidental. The videos feature the work of volunteer clinicians and actor pa-
tients who agreed to demonstrate commonly used interview techniques.
Introduction
Culture shapes every aspect of patient care in psychiatry, influencing

when, where, how, and to whom patients narrate their experiences of illness and dis-
tress (Kirmayer 2006), the patterning of symptoms (Kleinman 1977), and the models
clinicians use to interpret and understand symptoms in terms of psychiatric diagno-
ses (Kleinman 1987). Culture also shapes patients’ perceptions of care, including what
types of treatment are acceptable and for how long (Lewis-Fernández et al. 2013).
Even when patients and clinicians share similar cultural, ethnic, or linguistic back-
grounds, culture impacts care through other influences on identity, such as gender,
age, class, race, occupation, sexual orientation, and religion (Lu et al. 1995). Cultural
contexts and expectations frame the clinical encounter for every patient, not only for
underserved minority groups, and cultural formulation therefore is an essential com-
ponent of any comprehensive psychiatric assessment.
But how is cultural assessment to be carried out? What are its components? Can
only experts perform it, or can it be learned by any practicing clinician and imple-
mented in routine practice? How comprehensive must it be to be useful for mental
health care? Is it possible to develop a standard assessment approach for everybody,
or does every cultural group need its own method and content? Can the assessment
itself yield enough information, or is it necessary for the clinician to start out with
some background knowledge?
This handbook takes up many of these questions, marshaling the available evi-
dence in support of a standardized approach to cultural assessment, the DSM-5
(American Psychiatric Association 2013) Cultural Formulation Interview (CFI). A
product of the 2007–2013 DSM revision process, the CFI is composed of three types
of semistructured interviews that offer clinicians concrete ways to carry out the cul-
tural assessment of a patient and his or her entourage according to a revision of the
Outline for Cultural Formulation (OCF), first published in DSM-IV (American Psy-
chiatric Association 1994). The three components of the CFI are a core 16-item ques-
tionnaire; the CFI–Informant Version, which is used to obtain information from
caregivers; and 12 supplementary modules that expand on these basic assessments.
(The core CFI and CFI–Informant Version are published in DSM-5 and are available
xxvii
xxviii DSM-5 Handbook on the Cultural Formulation Interview
online along with the supplementary modules at www.psychiatry.org/practice/

dsm/dsm5/online-assessment-measures. In addition, the core CFI, CFI–Informant
Version, and 12 modules are included in the appendixes of this handbook.) The de-
velopers of the CFI, the DSM-5 Cross-Cultural Issues Subgroup (DCCIS), envisioned
the use of the CFI as a telescoping process, beginning with the core CFI, a basic as-
sessment that can be conducted with any patient in any mental health setting and
that can be learned and implemented with fidelity by any clinician. For some clinical
situations, this level of assessment may be sufficient. If used routinely to frame the
intake interview, the core CFI can help establish a foundation of person-centered in-
formation on the patient’s context and perspective, as well as a working alliance, on
which to build the rest of the diagnostic interview and treatment negotiation process.
If additional cultural information is needed, the other components of the CFI can be
called into play. When collateral information is desired, the CFI–Informant Version can
supplement what the patient reports, or it may become the primary source of informa-
tion when the patient is unable to participate actively in his or her care, such as in the
case of some young children or individuals with cognitive impairment or florid psycho-
sis. If the clinician sees the need for additional information, the supplementary modules
expand on the content obtained from the core assessments. Use of all of the modules
and the CFI–Informant Version along with the core CFI constitutes a fairly comprehen-
sive cultural assessment, particularly useful for situations involving the following:
• Difficulty in diagnostic assessment owing to significant differences in the cul-

tural, religious, or socioeconomic backgrounds of clinician and the individual
• Uncertainty about the fit between culturally distinctive symptoms and diag-
nostic criteria
• Difficulty in judging illness severity or impairment
• Disagreement between the individual and clinician on the course of care
• Limited engagement in and adherence to treatment by the individual (Ameri-
can Psychiatric Association 2013, p. 751)
Three kinds of supplementary modules are included (see Chapter 3, “Supplemen-

tary Modules”): Core CFI expansion modules amplify key sections of the core CFI (e.g.,
the Explanatory Model); specific populations modules assess particular populations
(e.g., older adults, refugees) who may have specific needs and experiences as a result
of certain aspects of their background or identity; and informant perspectives modules
clarify how individuals who assist the patient with his or her care and members of the
patient’s social network view the patient’s situation. Although the CFI–Informant
Version is not strictly one of the 12 supplementary modules, it can be considered an
informant perspectives module because it helps the clinician obtain a fuller picture of
the patient’s situation when combined with the core CFI. The CFI telescoping ap-
proach means that the clinician can select how much information to obtain and there-
fore how much time to dedicate to each aspect of the interview for his or her
particular purposes. Several components of the CFI can be obtained all at once, pos-
sibly during the initial interview, or at different points throughout the process of care.
Practical concerns were front and center in the work of the DCCIS. In current prac-
tice environments, the duration of the clinical visit is an important constraint for prac-
Introduction xxix
titioners, administrators, and health plans. To be taken up widely, interventions must

be feasible and cost-effective, or they risk remaining of academic interest only. In this
respect, the DCCIS faced a dilemma: how to revise the OCF to increase its functional-
ity for busy clinicians without weakening its role as a narrative, person-centered ac-
count of suffering that supplements the criteria-based diagnostic practice of
contemporary psychiatry (Lewis-Fernández 2009). The cultural formulation ap-
proach operationalizes a more thorough evaluation of the sociocultural context in
which illness experience is embedded. Without this systematic contextual assess-
ment, the meaning of much of patients’ illness behavior—including accurate calibra-
tion of symptom severity—may elude a busy provider, increasing the risk of clinical
mismanagement, patient dissatisfaction, nonadherence, and poor treatment re-
sponse. On the other hand, a long and complex cultural assessment approach that
will not be implemented in actual practice is of little practical value. To escape both
horns of the dilemma, the DCCIS developed the CFI to combine sufficient contextual
depth with functionality and to facilitate dissemination by operationalizing the inter-
view as a parsimonious, telescopic, but useful, set of questions (Lewis-Fernández
2009). The draft of the core CFI was revised based on clinician and patient feedback
obtained in an international field trial prior to its inclusion in DSM-5. The field trial
provided evidence of the CFI’s feasibility, acceptability, and perceived clinical utility
(R. Lewis-Fernández et al., Feasibility, acceptability and clinical utility of the core Cul-
tural Formulation Interview: Results from the international DSM-5 field trial, manu-
script in preparation, March 2015).
Although the CFI is designed to be integrated seamlessly into clinical practice, the
CFI is also designed to advance what is, in effect, a radical agenda: to change the way
clinicians conduct a diagnostic interview so that the perspective of the patient be-
comes at least as important as the signs and symptoms of disease identified by the cli-
nician (Kleinman 1988; Mezzich and Appleyard 2010). The mission of the CFI is, in
fact, to expand what counts as data in a clinical encounter (Marková and Berrios 2012;
Nordgaard et al. 2013), encouraging the clinician—and the patient, who is empow-
ered to recount his or her experience more fully—to attend to the experience of ill-
ness and the lifeworld (Aggarwal et al. 2015). This corresponds to the current person-
centered turn in mental health care, in which the patient’s voice—as well as that of the
patient’s family and other important people in his or her life—becomes a primary fo-
cus of the clinician’s attention (Mezzich 2007; Stanghellini et al. 2013). The CFI helps
to elaborate the patient’s perspective within a specific local world, such as the views of
the community—exemplified by the patient’s social network—and the life context in
which the problem presented emerges (Kleinman and Benson 2006). The CFI can help
clarify what the patient is looking for in the clinical encounter, the various possibilities
for treatment and other forms of self-coping and help seeking the patient can draw
upon, and, very specifically, the ways in which treatment will be carried out. The
greater understanding afforded to the clinician—paired with a fuller expression of the
problem, preferences for care, and trust on the part of the patient—should facilitate a
process of shared decision making (U.S. Department of Health and Human Services
2010), including negotiating and clarifying the subsequent concrete steps and deci-
sions for both partners in the session. Our hope is that by making the CFI questions
xxx DSM-5 Handbook on the Cultural Formulation Interview
easier for clinicians to ask, the usefulness of the information and rapport elicited by
these questions will encourage the routine use of the CFI in clinical care.
The CFI also carries forward another more challenging goal: to transmit a more so-
phisticated understanding of an individual’s experience of culture as a dynamic, con-
stantly changing distillation of multiple engagements with all the communities to
which he or she belongs, whether based on gender, spirituality, age, language, race/
ethnicity, occupation, geographical region, leisure activities, national origin, or any
other element of the person’s background and collective life. In the CFI, culture is re-
flected in the cognitive, behavioral, and emotional predispositions as well as the com-
monsense, taken-for-granted knowledge that affect a person’s values, thoughts,
perceptions, intuitions, bodily experiences, and practices—in short, every aspect of the
patient’s life. This includes interpretations of what constitutes a clinical problem, what
the patient’s illness—if any—may be, how to cope, and what help to seek, including
whether to access psychiatric care and what treatment to expect (Kleinman et al. 1978).
This also includes the commonsense, taken-for-granted knowledge of clinicians in the
health care system that should not be assumed for patients. In U.S. health care practice,
notions of culture are frequently paired exclusively with racialized/ethnic categories,
which may lead to the unintended consequence of stereotyping patients. As noted by
Arthur Kleinman, M.D., in the foreword to this book, the CFI challenges this view,
guiding clinicians to see the contextual frame of each patient’s experience—seeking to
use information about the collective to understand an individual’s perspective and to
clarify how local environments impinge on the person’s situation, including how so-
ciocultural contingencies help to pattern a set of events. The goal is to understand the
patient’s predicament—both the aspects of which the patient is aware and those that
are outside his or her awareness. Recognizing that the patient may not be able to pro-
vide all of this background, the intent of the CFI is to raise these questions for clinicians
to examine, possibly through additional sources of data, including collateral informa-
tion from relatives; reading literature on the person’s self-identified background
group(s); reflection on the clinician’s knowledge of the patient’s culture(s); and consul-
tations with culture brokers, interpreters, religious leaders, or other clinicians with rel-
evant experience. The CFI enables clinicians to construct a cultural formulation
genuinely based on the patient’s self-identified group, freeing the clinician from the
burden of incorrectly guessing group markers of identity—such as race and ethnic-
ity—or offering treatment recommendations based on inaccurate stereotypes. As the
above examples suggest, the CFI may be particularly revealing when it leads the clini-
cian beyond the individual patient interview to a greater engagement with the pa-
tient’s lifeworld, a gradual process that can enrich clinical care much beyond the focus
on symptoms and disorders so prevalent in contemporary psychiatry. Although the
clinician’s past experience with particular groups can guide and enrich the interview
process, the CFI can be implemented by clinicians with no explicit knowledge about
the cultural backgrounds of their patients. In this sense, it is a self-contained instru-
ment; however, its effectiveness is likely to increase with experience, both with the CFI
itself and with specific groups and contexts.
Just how effective is the CFI? Research is actively examining various types of clin-
ical usefulness. The potential research outcomes are legion: diagnostic accuracy;
Introduction xxxi
level of patient participation and engagement; intrasession processual and commu-

nication dimensions; treatment effectiveness; patient satisfaction, retention, and ad-
herence; cost-effectiveness; self-defined recovery; impact on level of care over time
(e.g., rehospitalization rates); effect on quality of life and illness-related impairment;
and so on. Chapter 2 (“The Core and Informant Cultural Formulation Interviews in
DSM-5”) presents the results of the DSM-5 international field trial in 14 sites across
six countries that tested the core CFI’s feasibility, acceptability, and clinical utility, as
reported by patients and clinicians. This trial showed that both patients and clini-
cians found the core CFI to be feasible, acceptable, and useful. These findings may
encourage clinicians to take up the CFI, patients to request its use, and educators to
include the CFI at all levels of clinical training. As more research is conducted, it will
be crucial to generate evidence that examines the impact of the CFI in order to deter-
mine the value of its widespread and sustained implementation.
Contents of the Handbook

This handbook is organized into six major chapters, two of which have multiple sub-
chapters. Chapter 1 (“Cultural Formulation Before DSM-5”) describes the founda-
tions of the CFI: the OCF and the various semistructured instruments that were
developed from it in North America and Europe prior to DSM-5. Chapter 2 (“The
Core and Informant Cultural Formulation Interviews in DSM-5”) introduces the core
CFI and the CFI–Informant Version, explaining the intent of each question and pro-
viding guidelines for their use in clinical practice. As stated above, it also reviews key
findings from the DSM-5 field trial on the feasibility, acceptability, and perceived clin-
ical utility of an early draft of the core CFI that was revised into the final version in
DSM-5 based on field trial results.
Chapter 3 (“Supplementary Modules”) introduces the supplementary modules; each
of 12 subchapters describes a module in detail, including guidelines for its use, exempli-
fied with case vignettes. Figure 3–1 presents all of the modules and their relationship to
the core CFI and the CFI–Informant Version. The subchapter on cultural identity focuses
first on cultural identity in general and is then further subdivided, describing three major
components of identity: national, ethnic, racial, language, and migration issues; spiritual-
ity, religion, and moral traditions; and gender identity and sexual orientation identity.
Chapter 4 (“Clinical Implementation of the Cultural Formulation Interview”) is
subdivided into three subchapters, addressing various aspects of the CFI implementa-
tion process in clinical care. Chapter 4 reviews how implementation strategies can fa-
cilitate uptake of novel interventions such as the CFI. It presents two possible CFI
implementation strategies—one for clinicians and the other for organizational teams,
the two groups of stakeholders ultimately responsible for delivering culturally com-
petent care to patients. The chapter covers seven dimensions whose clarity would con-
cretely operationalize implementation: the actors, the action, the action target,
temporality, dose, implementation outcomes affected, and justification. The subchap-
ter “Use of the Cultural Formulation Interview in Different Clinical Settings” docu-
ments issues that come up during the application of the CFI in diverse clinical
settings: emergency departments, consultation-liaison services (i.e., inpatient medical
xxxii DSM-5 Handbook on the Cultural Formulation Interview
and surgical units in general hospitals), outpatient clinics, and urban or rural com-
munity health centers. Each setting presents unique environmental and patient- and
staff-related features that are reviewed and illustrated with clinical vignettes. The sub-
chapter “Administrative Perspectives on the Implementation and Use of the Cultural
Formulation Interview” discusses CFI implementation from the point of view of ad-
ministrators in a busy multicultural clinic in San Francisco that participated in the
DSM-5 field trial. Administrators present the “business case” for the CFI, addressing
organizational purpose and need, use and benefits, implementation strategies, and im-
plementation challenges and potential solutions related to CFI uptake. The subchapter
“Application of the Cultural Formulation Interview in International Settings” de-
scribes the experience that various clinician investigators have had with the CFI ques-
tions in four international settings involved in the development of the CFI and/or the
DSM-5 field trial. Work is presented from India, Kenya, the Netherlands, Sweden, and
other Nordic countries and is illustrated by case vignettes. This subchapter also dis-
cusses how the CFI may need to be modified for international settings and what role
psychiatric practice in other countries may play in continuing to refine the CFI.
Chapter 5 (“Cultural Competence in Psychiatric Education Using the Cultural
Formulation Interview”) reviews current regulations and published guidelines on the
teaching of culturally appropriate assessment in medical student and resident train-
ing and continuing medical education and suggests how the CFI can be incorporated
into these efforts. Finally, Chapter 6 (“Conclusion: The Future of Cultural Formula-
tion”) provides some directions for the future development of the CFI and of cultural
formulation more generally, in terms of theory, research, and practice.
Conclusion
In summary, the CFI represents an important advance in cultural assessment for use
in routine clinical care. The CFI seeks to enhance the person centeredness of diagnos-
tic practice and treatment negotiation by focusing on the person’s experiences, views,
and expectations of illness and care as influenced by cultural background and con-
text. The goal is to help clinicians and patients communicate as effectively as possible
and overcome all barriers to the successful outcome of treatment. This handbook pro-
vides a starting point for the continued development and refinement of cultural as-
sessment as a central pillar of mental health practice.
KEY CLINICAL POINTS

• The three components of the Cultural Formulation Interview (CFI)—core CFI,
CFI–Informant Version, and supplementary modules—provide a flexible approach
to cultural assessment that can be tailored by the clinician to the needs of the pa-
tient and the clinical situation.
• The handbook text and accompanying videos provide detailed guidance on how to
use the CFI.
Introduction xxxiii
Questions
1. What is the rationale for including the CFI in DSM-5?
2. In what ways does the CFI represent an advance on previous approaches to

cultural formulation?
3. How is culture defined in the CFI?
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xxxiv DSM-5 Handbook on the Cultural Formulation Interview
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Suggested Readings
Kirmayer LJ, Guzder J, Rousseau C (eds): Cultural Consultation: Encountering the Other in
Mental Health Care. New York, Springer, 2014
how to fix it. PLoS Med 3(10):e294, 2006
CHAPTER 1
Before DSM-5
The introduction of the Outline for Cultural Formulation (OCF) in DSM-IV

(American Psychiatric Association 1994) marked a transition from an earlier period of
general recommendations for conducting cultural assessments in psychiatry (Klein-
man 1980) to the beginning of a series of efforts to systematize the application of cul-
tural assessments in routine clinical practice. As an early attempt at systematization,
the DSM-IV OCF was developed as a conceptual framework—a summary of the top-
ics that should be included in a cultural assessment during a mental health evaluation
to improve diagnostic accuracy and patient engagement in treatment planning. Over
the last two decades, mental health clinicians, researchers, and social scientists in sev-
eral countries have worked to refine the OCF and make it even more user-friendly for
clinicians and mental health trainees by illustrating its application in questionnaires,
protocols, and semistructured interviews. This work on operationalizing the cultural
assessment process led to the Cultural Formulation Interview (CFI), a set of semistruc-
tured instruments included in DSM-5 (American Psychiatric Association 2013) that
show how to collect information for the OCF (note usage of CFI to indicate multiple
components and core CFI to indicate the 16-question interview). The CFI is composed
of three parts: a core 16-item questionnaire (Appendix A in this handbook), an infor-
mant version of the core CFI to obtain information from caregivers (Appendix B), and
12 supplementary modules that expand on these basic assessments (Appendix C).
This handbook describes the development of the CFI, the content of each of its
components, and recommendations for how to apply them in mental health care, in-
cluding how to train clinicians in their use. This chapter takes a first step toward our
1
2 DSM-5 Handbook on the Cultural Formulation Interview
goal by describing the foundations of the CFI: the OCF and the various semistruc-
tured instruments that were developed from it in North America and Europe prior to
the publication of DSM-5. To summarize this foundational material, we combine two
sources of information: 1) findings from a series of literature reviews on the OCF do-
mains conducted by members of the DSM-5 Cross-Cultural Issues Subgroup (DCCIS)
that were used to develop the CFI and 2) a summary of the main conceptual issues
raised by the DCCIS during the DSM revision process (Lewis-Fernández et al. 2014).
Outline for Cultural Formulation

The OCF is a conceptual framework that was developed to encourage clinicians to
identify the impact of culture on key aspects of an individual’s clinical presentation
and care (Mezzich et al. 2009). According to the DSM-IV text, the OCF was “meant to
supplement the multiaxial diagnostic assessment and to address difficulties that may
be encountered in applying DSM-IV criteria in a multicultural environment” (Amer-
ican Psychiatric Association 1994, p. 843).
The DSM-IV OCF organized clinical information into four domains: 1) cultural
identity of the individual; 2) cultural explanations of the individual’s illness; 3) cul-
tural factors related to psychosocial environment and levels of functioning; and 4) cul-
tural elements of the relationship between the individual and the clinician.
Information from these domains influencing diagnosis and treatment was summa-
rized and synthesized in a fifth section to provide an overall formulation (American
Psychiatric Association 1994). Social theory and clinical-ethnographic research guided
the original delineation of the domains, including the role of identity in clinical presen-
tation (domain 1), cultural meanings and explanatory models of illness (domain 2), so-
cial networks providing support or stressors affecting functional capacity (domain 3),
and the professional’s reflections on the patient-clinician relationship (domain 4)
(Mezzich 2008). A key goal of the OCF has always been to yield an account of the pa-
tient’s illness that captures his or her symptom experience along with personal and
cultural interpretations and the social contexts or circumstances of the illness. This in-
formation may help identify causal explanations and meanings of illness by the pa-
tient and by his or her family and community and extends a biopsychosocial
formulation into the realm of cultural assessment (Kleinman 1988; Lewis-Fernández
and Díaz 2002; Mezzich 1995).
The OCF was reprinted without revision in DSM-IV-TR (American Psychiatric As-
sociation 2000). In DSM-5, the OCF was revised by making the DSM-IV-TR text more
explicit in places. Examples of this clarification include the following: incorporating
elements of cultural identity not mentioned in DSM-IV-TR (e.g., religious affiliation,
sexual orientation); instructing clinicians to identify actual stressors and supports in
the patient’s environment as well as how they are interpreted by the individual and
the clinician in relation to the social context; and mention of the potential impact of
racism and discrimination on the clinician-patient relationship. However, the content
of the OCF has remained roughly unchanged since 1994.
The OCF has been used worldwide. Educators have employed it in training pro-
grams in Canada, Denmark, India, the Netherlands, Norway, Spain, Sweden, the
Cultural Formulation Before DSM-5 3
United Kingdom, and the United States (e.g., Jadhav 2010a; Kirmayer et al. 2012; Lim
2006; Østerskov 2011). In the United States, the OCF is commonly part of psychiatric
training. In a qualitative study with 20 preceptors of cultural psychiatry from U.S.
adult psychiatry residency programs, 70% had at least one class on the OCF, usually
during the first 2 years (Hansen et al. 2013). Similarly, centers providing outpatient
mental health services to migrants and refugees in Sweden (Bäärnhielm and Scarpi-
nati Rosso 2009) and the Netherlands (Rohlof et al. 2009) have used the OCF for stan-
dard clinical assessment.
The diagnostic utility of the OCF has been documented in numerous case reports
and case series in various countries (e.g., Lewis-Fernández 1996; Rohlof et al. 2009).
The most extensive literature beyond case studies comes from a cultural consultation
service (CCS) at the Jewish General Hospital in Montreal, Quebec, Canada, that re-
ceives referrals from primary care clinicians and mental health practitioners seeking
to address barriers to care that they attribute to cultural differences (e.g., failed rap-
port, poor adherence) (Kirmayer et al. 2003, 2014). The consultation procedure in-
volves clinical assessment by a team including a psychiatrist or psychologist, an
interpreter, and a culture broker and follows an interview guide based on an ex-
panded version of the DSM-IV OCF developed by the CCS (Kirmayer et al. 2014). The
assessment interviews typically involve one to three 1-hour sessions and usually in-
clude family members. The information collected through this interview process is
integrated into a case formulation at a multidisciplinary case conference. Culture bro-
kers are individuals with lived experience in the patient’s cultural reference
group(s)—frequently community members—who have been trained to bridge (“bro-
ker”) potential communication gaps between local and professional perspectives
(Miklavcic and LeBlanc 2014). At the CCS, findings from the OCF-based assessment
are routinely discussed in a multidisciplinary case conference with all members of
the cultural consultation team to develop a cultural formulation (Kirmayer et al.
2014).
Use of the OCF was well received by consultants and culture brokers working in
the CCS. On a survey inquiring about their use of the DSM-IV OCF and the CCS ver-
sion, 93% of them found the expanded OCF interview to be useful, although many
were unfamiliar with the DSM-IV tool or had not used it before (Kirmayer et al.
2008b). In terms of diagnostic impact, use of the OCF resulted in substantial rates of
rediagnosis: overall, cultural formulation led to a rediagnosis in about 60% of 400
cases seen by the service (Kirmayer et al. 2014). In one study, 49% of 70 patients with
a referral diagnosis of psychotic disorder were rediagnosed as nonpsychotic after
OCF-based assessment (Adeponle et al. 2012). Many of the patients misdiagnosed
with a psychotic disorder were immigrants or refugees suffering from posttraumatic
stress disorder, adjustment disorder, and other stress-related conditions. Rediagnosis
from psychotic to nonpsychotic disorder was more likely among patients who had re-
cently arrived in Canada and were referred from nonmedical sources (e.g., social
workers or occupational therapists).
Although the OCF was found to be a useful clinical tool in much of this previous
work, problems with its implementation have also been identified. Guidance has
been lacking on when, with whom, and why to use the OCF (Cuéllar and Paniagua
2000). Clinicians have struggled to find ways to cover the many topics included in the
four broad domains of the OCF within the time constraints of various practice set-
tings (Lewis-Fernández 2009). Some subsections of the OCF may be imprecise and
overlapping, and some important topics were absent in the DSM-IV version (Ton and
Lim 2008). It is not clear which components of the OCF are particularly relevant for
treatment planning and adaptation of clinical approaches and therefore should be
emphasized in practice (Mezzich et al. 2009). Although the OCF is framed in terms of
patients’ knowledge and experience, the use of the OCF with children, immigrants
and refugees, homeless populations, individuals with limited literacy, and the elderly
may require collateral sources of information or local adaptations (Aggarwal 2010a,
2010b; Groen 2009b; Rohlof et al. 2009). The lack of a standard approach to the OCF
has hindered generalizable research, and the lack of guidance on how to collect rele-
vant information has limited clinical uptake (Mezzich et al. 2009).
Development of OCF-Related Interviews

Prior to DSM-5
The concerns described in the section “Outline for Cultural Formulation” prompted
efforts in various countries to make the OCF more user-friendly for clinicians by in-
cluding lists of suggested questions, protocols for topics to be covered during OCF-
based assessments, and semistructured interviews (Table 1–1). Interview approaches
to the OCF were developed in Canada (Kirmayer et al. 2001), the Netherlands (Groen
2009a; Rohlof et al. 2002), Sweden (Bäärnhielm and Scarpinati Rosso 2009), the United
States (Mezzich et al. 2009), the United Kingdom (Jadhav 2010a, 2010b), and Denmark
(Østerskov 2011). All of these interviews were designed to enhance clinical assess-
ment and treatment planning rather than to elicit research data. In related work, more
detailed interviews were developed for research focusing on cultural variations in ill-
ness experience and explanatory models, including the Explanatory Model Interview
Catalogue (Weiss 2001) and the McGill Illness Narrative Interview (Groleau et al.
2006). Developers of many of these interviews and instruments were members of the
DCCIS, and their experience informed the preparation of the CFI.
In the sections that follow, we summarize work on each OCF domain and its op-
erationalization prior to DSM-5. We also review challenges that emerged when imple-
menting the OCF in clinical practice. Key themes and implications for the CFI in
DSM-5 that emerged from the work of the DCCIS are summarized in Table 1–2. Each
section below is based on the deliberations of the DCCIS and on English-language lit-
erature reviews since 1994, augmented by references from 1965 to 1994 and by addi-
tional material in Danish, Dutch, French, Norwegian, Spanish, and Swedish when
appropriate (Lewis-Fernández et al. 2014).
Cultural Formulation Before DSM-5
TABLE 1–1. Inclusion of Outline for Cultural Formulation domains in question lists, assessment protocols, and
semistructured clinical interviews prior to the Cultural Formulation Interview
Canadaa Netherlandsb Swedenc United Statesd United Kingdome Denmarkf
Cultural identity
Cultural reference group(s) √ √ √ √ √ √
Patient’s and key relatives’ cultural identifications √ √ √ √ √ √
(e.g., ethnic, religious, national)
Cultural identity of key members of social network √ √ √ √ √
(e.g., parents, relatives, friends)
Importance or meaning to patient/family of cultural √ √ √ √
identification
Perceptions of patient’s identity by others √ √
Experience of multiple identities and/or changes of √* √ √ √
identity over time
Relationship of cultural identity factor(s) to problem √
presented
Characteristics of culture of origin and differences √
from host culture
Language √ √ √ √ √ √
Language use by developmental period and setting √ √ √ √ √
(e.g., at home, in health care)
Language(s) in which patient is literate √ √
Perceived fluency in language of host culture √
Cultural factors in development √
5
6
semistructured clinical interviews prior to the Cultural Formulation Interview (continued)
Involvement with culture of origin (e.g., country of ori- √ √ √ √ √

gin, migrants from same origin)
Importance/frequency of involvement to patient √ √ √ √
Perceptions of culture of origin √ √* √ √
Elements of culture of origin that are missed/relieved √* √ √ √
DSM-5 Handbook on the Cultural Formulation Interview

to have left
Involvement with host culture (e.g., peers, food, news) √ √ √ √ √ √
Perceptions of host culture (e.g., racism, values relative √ √ √ √ √ √
to culture of origin, opportunities)
Relationship of engagement with host culture to pre- √
senting problem
Migration history (e.g., reasons, route, journey experi- √ √ √g √
ence, hopes, people left behind)
Cultural explanations of the individual’s illness

Predominant idioms of distress and illness categories, √ √ √ √ √ √
including illness/problem label
How patient describes problem to social network √ √
How social network/culture of origin describes prob- √ √ √ √ √
lem
Most troubling aspect of problem to patient √
Meaning and severity of symptoms in relation to cul- √ √ √ √ √ √

tural norms
Patient’s views (e.g., of severity) √ √ √ √ √
Views of social network √ √ √ √ √
In relation to norms of host culture (e.g., clinicians) √ √ √
Impact on patient’s life/biggest fear √ √
Perceived causes and explanatory models (e.g., illness √ √ √ √ √h √
mechanism[s], course, expected outcomes)
Views of social network (e.g., of causes) √* √ √ √ √
Prototypes (e.g., knowledge of anyone with same prob- √ √ √ √
lem)
Treatment expectations (e.g., preferred treatment, con- √ √* √ √ √ √
cerns)
Help-seeking experiences and plans √ √ √ √ √ √
Treatments sought or planned in formal health care √ √* √ √ √
system
Most useful treatment received √ √
Help/treatment recommended in country of origin/by √* √
social network
Use of traditional healers and alternative services √ √* √ √ √ √
7
8
Cultural factors related to psychosocial environment and levels of functioning

Social stressors in relation to cultural norms √ √* √ √ √ √
Social network’s perception of stressors √ √
Impact on patient √ √ √ √

Relationship with partner √ √
Social supports in relation to cultural norms √ √ √ √ √ √
Role of religious/spiritual supports (e.g., prayer) √ √ √ √
Barriers to receiving supports √
Levels of functioning and disability in relation to cul- √ √ √ √ √
tural norms
Views of social network and culture of origin on levels √
of functioning/disability
Cultural elements of the relationship between the individual and the clinician
Patient’s views of the relationship √ √ √ √
Experience of quality of communication/language √* √ √ √
use during interview
Important topics not covered √* √ √ √
Perception of own role during interview (e.g., should √
I ask questions?)
Importance to patient of match with clinician (e.g., √
gender, faith)
Clinician’s views of the relationship √ √* √ √ √ √

Experience of quality of communication/language √ √* √ √ √ √
use during interview
Awareness of own culture/historical relationships of √ √ √ √
patient and clinician cultures of origin
Impact of intercultural differences/similarities (e.g., √ √* √ √ √ √
on diagnosis, engagement, treatment plan)
Note. The countries are presented following the order of publication of their respective instruments.
aKirmayer et al. 2001 (English).
b
Rohlof 2008, Rohlof et al. 2002 (items included in abbreviated version by Groen 2009a are noted with an asterisk; Dutch and English).
c
Bäärnhielm et al. 2007, 2010a, 2010b (Swedish, English, Finnish, and Norwegian).
dMezzich et al. 2009 (English).
eJadhav 2010a, 2010b (English).
f
Østerskov 2011 (Danish).
gUtilizes a map of the world to trace migration journey.
hUtilizes a schema of the human body to trace mechanisms of illness/treatment.
Source. From Lewis-Fernández et al. 2014. Reprinted with permission.
9
10
TABLE 1–2. Key themes and implications for DSM-5 related to the Cultural Formulation Interview (CFI) and its clinical
implementation
CFI as an intervention
OCF domain Key themes Implications for DSM-5

Cultural identity of the Patients’ cultural identities should be assessed directly— The CFI includes open-ended questions that allow patients
individual rather than assigned by the clinician—including asking to narrate their own cultural identities.
about how these change with context. Cultural identity is conceptualized broadly to include cul-
Key aspects of identity from previous OCF instruments ture, race, ethnicity, gender, religion, language, geograph-

include patient’s multiple cultural identifications, their ical origin, and sexual orientation.
meaning for the patient and the social network, language
Inquiry about cultural identity is linked to its impact on the
use, relationship of identity with presenting problem, and
clinical problem, treatment choices, other aspects of care,
immigrants’ separate involvement with culture of origin
and life problems in general.
and host culture.
Assessment of identity presents particular challenges for Supplementary modules for this topic and by patient pop-
specific groups (e.g., youth, older adults, refugees). ulation can be used for detail.
Cultural explanations of Patients’ narrations of illness present diversely, as logical The CFI uses open-ended questions to elicit illness models
the individual’s illness explanations or as more metaphorical accounts, and may from patients and their close associates, allowing for
change with context. exploration of all types of illness models.
Eliciting the views of patients’ friends and family may clar- Using patient illness terms as prompts may reveal cultural
ify which illness models are most relevant to care. information and facilitate engagement.
Culture also affects patients’ communication styles, Attention to past experiences of care and current treatment
engagement expectations, and preferences for care. preferences can improve patient engagement.
Previous OCF operationalizations inquire about illness idi- Identifying potential barriers to care early in treatment may
oms, symptom meaning and perceived severity, causes, allow clinicians to address them.
course, past care, and treatment expectations, usually Supplementary models allow greater exploration of illness
from both the patient and close associates. models as needed.
implementation (continued)
CFI as an intervention
OCF domain Key themes Implications for DSM-5

Cultural factors related to Assessment should combine patients’ subjective experi- The CFI follows the subjective-objective approach by
psychosocial environ- ence of stressors, supports, and levels of functioning with emphasizing documentation of patient and clinician
ment and levels of func- clinicians’ objective analysis of the social and cultural con- interpretations about social supports, stressors, and levels
tioning text. of functioning.
Multiple social factors increase risk for psychopathology;
The CFI may be used with all patients, assessing experi-
diverse social groups face discrimination due to their
ences of diverse social groups.
devalued social status and should be assessed.
Open-ended questions assess supports, stressors, and the
The impact of religion, spirituality, and moral traditions on
most troubling aspect of the presenting problem.
coping is often neglected.
Previous OCF instruments prioritize impact of stressors on Supplementary modules for informants, levels of function-
the patient, role of spiritual support, and the views of ing, psychosocial stressors, special patient populations,
close associates. and religion/spirituality/moral traditions can be used for
detail.
Cultural elements of the Facilitating clinician self-reflection via standardized ques- The CFI inquires about previous experiences with racism
relationship between the tions on the clinician-patient relationship can help reduce and discrimination in clinical care.
individual and the clini- unintended stereotyping and bias and increase rapport
cian and engagement.
Previous OCF instruments address this topic through ques- The CFI focuses on barriers to treatment, such as lack of
tions aimed at the clinician, the patient, or both. resources or of culturally competent professionals or ser-
Raising these sensitive issues early in care (e.g., during vices that may impact the patient-clinician relationship.
intake) may show willingness to overcome past treatment The Patient-Clinician Relationship supplementary module
barriers in the current therapeutic relationship. contains additional questions for patients and clinicians
to self-reflect on how their backgrounds and the health
system affect care.
11
12
implementation (continued)
Implementing the CFI in service settings
Implementation topic Key themes Implications for DSM-5

Contexts of use Best-practice recommendations have varied as to when, The CFI is designed to initiate the standard clinical intake.
where, and how to use the OCF (e.g., routine care with all The CFI can be used with all patients by all clinicians or
patients vs. only for overcoming specific culture-related adjunctive staff in all settings.
barriers). Special situations may be especially important for CFI use,

There are advantages and disadvantages to having clini- as when clinicians are unfamiliar with the patient’s cul-
cians themselves or adjunctive staff obtain information ture or disagree with the patient’s preferences and expec-
using the OCF. tations of care.
Length and content Length and content of previous OCF operationalizations To facilitate use, the core CFI consists of 16 questions for all
have varied, reflecting the diverse clinical settings and patients.
cultural contexts of use. Supplementary modules can be used to balance the level of
cultural information needed with clinical constraints on
time and priorities of the clinical setting.
Training Standardized training protocols are a necessary step in the The CFI has clear written guidelines for clinicians to follow
large-scale implementation of the CFI. during training.
CFI training approaches may be guided by past efforts A training video is currently in preparation. When it
focused on the OCF, including case supervision, class pre- becomes available, it will be announced at
sentations of formulated cases, didactic review, and more www.nyspi.org/culturalcompetence.
advanced experiential, self-reflective, and ethnographic The CFI may respond to ACGME requirements for psychi-
methods. atric residents and program directors to demonstrate cul-
tural competence throughout different aspects of training.
Note. ACGME=Accreditation Council for Graduate Medical Education; OCF=Outline for Cultural Formulation.
Source. From Lewis-Fernández et al. 2014. Reprinted with permission.
Key Themes Related to the CFI

as an Intervention
Cultural Identity of the Individual
Cultural psychiatrists regard understanding a patient’s cultural identity as indispens-
able to evaluation. Much of what clinicians understand as culture relates to a person’s
identity: What is the patient’s cultural background—for example, in terms of ethnic-
ity, religion, socioeconomic status (SES), or nationality? What languages does the pa-
tient speak? What groups does the individual relate to regularly or, by contrast,
avoid? What are the individual’s values regarding, for example, health, health care,
and spirituality? What aspects of the patient’s experience, such as child-rearing prac-
tices or migration, have shaped his or her perception of self and possibly his or her
illness?
Cultural identity can be ascribed to the person by others, on the basis of perceived
characteristics, or can be self-defined (Kirmayer et al. 2008a). Self-defined cultural iden-
tity can be understood as the part of a person’s self-construal that is related to the feel-
ing of belonging to one or more cultural groups, including the history of one’s past
group affiliation(s) and future aspirations in relation to one’s cultural group(s) (Wein-
reich 1986). Ascriptions of identity by others may be accepted or resisted by the person
but will have an impact on his or her self-construal and social identity, as well as the
response of others.
Cultural identity was included in several of the questionnaires, protocols, and in-
terviews that operationalized the OCF prior to the CFI. Certain aspects were in-
cluded in nearly all instruments: determining the cultural groups with which
patients identify; establishing the importance and meaning ascribed by patients and
their families to this identification; assessing language use, including by develop-
mental period and setting; and determining the patients’ involvement with the cul-
tures of origin and resettlement for immigrants, including both positive and negative
experiences (Table 1–1). These aspects of identity were prioritized in the CFI.
Several key points about identity emerge from work on the OCF. First, assessment
of cultural identity should be comprehensive. Many aspects of experience shape the
person’s identity. Early guidelines on cultural assessment (Lu et al. 1995) suggested
assessing cultural identity through an “interpersonal grid” (p. 483) documenting eth-
nicity, race, geographical origin, language, acculturation, gender, age, sexual orienta-
tion, religious or spiritual beliefs, socioeconomic class, and education. Cultural
assessment must inquire about these aspects of identity directly, to avoid stereotyp-
ing patients or simplifying sociocultural phenomena based on a clinician’s determi-
nation of the patient’s identity (Lewis-Fernández 1996).
Second, cultural assessment must recognize that a person’s identity may shift
across time, context, and expectations. Identity is always framed in relation to the per-
son’s past history, current concerns, and future prospects. Moreover, the ways that
people think about and describe their identity depend on the setting and the interloc-
utor. The OCF attempts to clarify how a person’s cultural identity can change with
context (e.g., with family members compared with strangers from a different ethnic-
ity), including how the patient’s own experience of identity is affected by his or her
perception of the clinician’s identity (Aggarwal 2012; Yilmaz and Weiss 2000). Some-
times a patient may emphasize, consciously or unconsciously, aspects of identity that
are closer to his or her view of the clinician’s background. An immigrant, for example,
may stress his or her shared identity with the clinician (as an “American” or as a
member of a particular ethnocultural, racial, or other group) rather than emphasizing
their cultural differences (Laria and Lewis-Fernández 2015).
The third point is related to the second: a person’s identity is never one-sided; peo-
ple have many facets or strands to their identity. The various strands that contribute
to one person’s identity may come from very disparate sources—one or multiple re-
ligions, several ethnic or racial backgrounds in the family, different geographical dis-
placements, the meaning ascribed in different places to belonging to a certain
generation, or evolving gender and sexual orientation identities, to name just a few.
Individuals who have undergone marked cultural shifts, such as immigrants and ref-
ugees, can experience their identity in complex ways, as different elements of their
background come to the fore in response to particular developmental transitions, life
choices, stresses, and social situations. Assessing this “hybrid” nature of identity is
important, including how it changes over time and in relation to illness (Aggarwal
2010a). Conflicts over sense of identity can cause substantial internal and interper-
sonal distress and influence the person’s clinical presentation.
Fourth, a comprehensive assessment of cultural identity should help the clinician
recognize the influence of identity, distress, stigma, language, and other cultural fac-
tors on the patient’s clinical presentation and concerns as well as modes of symptom
expression, illness interpretation, and help-seeking expectations. Assessment of cul-
tural identity in mental health must be attentive to the ways the person’s identity in-
teracts with other cultural and contextual influences to pattern multiple aspects of the
person’s problem in the context of care. All of these aspects of cultural identity are dis-
cussed further in the subchapter “Supplementary Module 6: Cultural Identity.”
Assessment of cultural identity may involve challenges for particular popula-
tions. Refugees may be suspicious of questions about identity, and many migrants
may not know how to describe or discuss their identities with clinicians unfamiliar
with their geographical, political, and historical backgrounds (Rohlof et al. 2009).
Children and adolescents may have different identities than their parents depending
on mixed parentage, adoption (Rousseau et al. 2008), and acculturation as a result of
migration (Aggarwal 2010a). The identity of older patients may be shaped by cultural
meanings of old age based on social roles and status (Aggarwal 2010b). The CFI paid
particular attention to the assessment of identity in these populations through the de-
velopment of supplementary modules.
Cultural Explanations of the Individual’s Illness

Comparing previously developed OCF instruments reveals that all include questions
on illness-related idioms, symptom meaning (and usually severity) in relation to cul-
tural norms, causes, expected course of illness, experiences with care, and treatment
expectations (Table 1–1). These, as well as other commonly elicited domains, were in-
cluded in the CFI (Lewis-Fernández et al. 2014).
The research on cultural explanations of illness most directly relevant to the CFI
involves anthropological methods that are person centered (Kirmayer and Bhugra
2009). Medical and psychological anthropology have developed methods for eliciting
and analyzing patients’ explanatory models of illness, which may include experi-
ences and ideas about onset, causes, mechanisms, course, and treatment expectations.
Arthur Kleinman’s seminal description of explanatory models emphasized informa-
tion about causality, mechanisms, and anticipated outcomes (Kleinman 1980). Ethno-
graphic fieldwork has shown that in everyday explanatory accounts of illness, people
may use multiple types of knowledge and modes of narration. For example, patients
may link symptoms to explanations based on chain complexes (Kirmayer et al. 1994;
Young 1981, 1982) because they were closely connected in time and space (contiguity)
or as a result of logical shortcuts to denote complex experiences (e.g., metonymy),
such as using the term nerves to refer to the anatomical and functional aspects of the
nervous system, including the feelings and sensations it mediates, much as journal-
ists use the term Washington to refer to the entire U.S. government. People also com-
monly use illness prototypes—illness episodes, experienced previously by the
individual or by others, that provide salient examples used to reason analogically
about one’s own experience (Young 1981, 1982). In effect, patients’ illness narratives
may combine models common to a cultural group, idiosyncratic assemblies of related
or even disconnected events, and models based on past experiences (Kirmayer et al.
1994).
Illness models also change in response to context, including interviewer and loca-
tion, as well as interactions with family, community, or health care system; during the
adaptation or acculturation of immigrants to new cultural contexts; and even over the
span of a long interview, as trust is established and memories are evoked. Further-
more, culture also influences elicitation of illness models. Cultural norms affect pa-
tient communication with providers, family, and friends. Eliciting the experiences,
views, and expectations of illness (illness representations) of the patient’s family mem-
bers, friends, or close associates can clarify the range of views influencing the illness
experience. The organization of health care services may also determine attitudes to-
ward disease, diagnosis, and treatment; for example, patients may emphasize physi-
cal symptoms and expect somatic remedies when working with physicians as
opposed to nonmedical therapists (Kirmayer and Bhugra 2009; Weiss and Somma
2007).
Eliciting past and current expectations of care are important goals of the OCF sec-
tion “Cultural explanations of the individual's illness.” Following broadly accepted
cultural “scripts,” illness representations may be associated with specific types of
self-coping and help seeking, including the perceived relevance and efficacy of men-
tal health treatments (L.J. Kirmayer, L. Ban, V. Fauras, et al., “Illness Explanations in
the Cultural Formulation,” paper prepared for DSM-5 Work Group, Culture and
Mental Health Research Unit, Montreal, 2012.). For example, the cultural script for
psychiatric distress understood as the result of sinful behavior and loss of religious
faith is likely to include more frequent prayer, revitalization of church attendance,
and increased involvement with one’s faith community rather than use of psychiatric
medication. Cultural adaptations of treatment interventions that incorporate cultural
scripts or explanations may enhance patient engagement and outcomes, indicating

the value of identifying cultural models and meanings before treatment (Griner and
Smith 2006). Nonmedical forms of self-coping and help seeking are common and
merit clinical attention because they may complement or conflict with psychiatric
care. Barriers to service utilization also reflect cultural priorities for care, family val-
ues and interactions, and local health system factors affecting access.
Earlier OCF guidelines (Lu et al. 1995) included culture-bound syndromes in the
section on cultural explanations of illness. In DSM-5, the term culture-bound syndrome
has been replaced by three newer terms: cultural syndromes, cultural idioms of distress,
and cultural explanations (American Psychiatric Association 2013). In reviewing the lit-
erature for DSM-5, members of the DCCIS recognized that few disorders around the
world are truly “bound” to one culture; cases are found in other cultural contexts with
similar illness models, and sporadic cases are found across very diverse societies.
Moreover, all disorders—including those described in North America—are influ-
enced by the cultural context of the patient. Also, many cultural concepts or illness
terms do not refer to “syndromes”—that is, they do not reference a relatively invari-
ant pattern of co-occurring symptoms. To avoid confusion, these newer terms distin-
guish among culturally shaped or influenced symptom clusters (syndromes); common
modes of expressing distress (idioms), which may not involve specific symptoms; and
explicit causal models, attributions, or explanations. Patient clinical presentations
may be influenced by these cultural concepts and modes of expression. Although the
same illness term may be used with all three meanings at times, it is clinically useful
to understand how the term or construction is functioning for a given patient.
Cultural Factors Related to Psychosocial Environment

and Levels of Functioning
The OCF directs clinicians to clarify cultural interpretations of the stressors and sup-
ports associated with a patient’s illness and the fears and hopes affecting levels of
functioning. The goal is a description of the context in which the illness emerged and
the current situation through the perspectives of the patient and others close to him
or her.
The pre–DSM-5 OCF instruments assess stressors, supports, and levels of func-
tioning in different ways. Alternatives include focusing on the impact of stressors on
the patient, the views of the social network, the role of the person’s partner and/or of
spiritual support, barriers to receiving help, and the views of the social network on
resulting levels of functioning. Pre–DSM-5 instruments used open-ended questions
to obtain a richer picture of these topics.
The illness experience of the patient and the responses of family members or oth-
ers in the social network are important because stress and support are strongly influ-
enced by cultural meanings and practices, which shape the perceived centrality,
magnitude, and tractability of the problem (Bäärnhielm and Scarpinati Rosso 2009).
As part of personal coping styles or culturally influenced modes of self-presentation,
patients may minimize or amplify stress, social support, and level of functioning;
hence, collateral information from family members or others in their entourage can
clarify clinically relevant aspects of the psychosocial environment. During assess-

ment, the person’s internal, subjective experience is interpreted through the clinician’s
external analysis of the social and cultural context. Like evaluating stress and social
support, the functional assessment of activities of daily living includes the interpre-
tations of patients and their social networks in relation to cultural norms of function-
ing (see subchapter “Supplementary Module 4: Psychosocial Stressors”).
Ethnocultural minorities and racially identified groups may face distinctive
stressors associated with their social status. Migration status is a potent social deter-
minant of health for refugees independent of premigratory trauma (Kirmayer et al.
2011). Factors most associated with risk for psychopathology include low SES, poor
housing, unemployment or underemployment, lack of residency, linguistic barriers,
limited social networks, discrimination, role strain, family conflict, status loss, accul-
turative stress, nostalgia, and bicultural tension (Bhugra 2004; Finch and Vega 2003;
Hovey and Magaña 2002; Tartakovsky 2007). Discrimination affects various social
groups, such as religious minorities, lesbian-gay-bisexual-transgender-queer per-
sons, and low-SES and disability communities, whose subjective experience of stress
and coping should be assessed. Questions may need adaptation to address the expe-
rience of discrimination, social position, and specific predicament of the patient.
To adequately assess social stressors and supports, an operationalized OCF needs
to obtain collateral information from the patient’s social network; this is important for
all patients but is especially so for children and adolescents and older adults. Simi-
larly, there is a need for guidance on obtaining information through medical inter-
preters and culture brokers (Mezzich et al. 2009; Rohlof et al. 2009; Rousseau et al.
2008).
Finally, any assessment of help seeking must consider the fact that patients often
turn to religion, spirituality, and moral traditions to understand and respond to men-
tal illness. There is a “religiosity gap” between clinicians trained in positivistic scien-
tific methods who may disparage religion and patients who search for holistic
treatments and are invested in religious beliefs and practices (Lukoff et al. 1992). Cul-
tural assessment thus should attend to the meanings and practices associated with re-
ligion in illness experience, especially when a religious community provides support
(Whitley 2012). Such information can help to mobilize support that contributes to re-
covery.
Cultural Elements of the Relationship Between

Individual and Clinician
The relationship between patient and clinician is influenced by the expectations, role
definitions, and resources each brings to the encounter. Evaluating this interaction is
an important dimension of cultural assessment and requires self-reflection on the
part of the clinician. Many OCF case studies illustrated challenges in providing cross-
cultural care. These included tensions between biomedical treatment and other
forms of healing (Barrett 1997), the failure of health systems to provide interpreters
(Bucardo et al. 2008), and difficulties in communication (Yilmaz and Weiss 2000).
Many of these are structural issues, but some reside primarily in the quality of the
clinical relationship and communication. In several studies (e.g., Groen 2009b), clini-
cians discussed tensions between considering the patient individually and consider-
ing him or her as part of a social group. Despite clinicians’ best efforts, the medical
encounter may be influenced by stereotyping, discrimination, racism, and subtle
forms of bias.
Existing instruments address this domain differently (Table 1–1). Some focus on
the clinician, providing queries to consider rather than questions addressed to the
patient. The Montreal CCS interview (Kirmayer et al. 2001) includes questions on the
mutual perceptions of power and positioning of the patient and clinician, including
historical relations between their respective cultural groups. The concepts of cultural
transference and cultural countertransference are thus mobilized to analyze patient-
physician relationships (Comas-Díaz and Jacobsen 1991; Mezzich et al. 2009). Other
instruments suggest questions for the patient, including on the quality of communi-
cation, the need for interpreters, topics missed during the interview, the impact of
cultural matching with the clinician, and the role of the patient. Open inquiry into
the sensitive topics of negative treatment experiences and potential miscommunica-
tions early in care (e.g., during intake) may facilitate rapport and engagement be-
cause it conveys a commitment to overcome treatment barriers; it also acknowledges
from the beginning that both patients and clinicians bring their cultural perspectives
to bear on the clinical encounter and that these perspectives may evolve and interact
over the course of care.
Key Themes Related to Implementation

of the CFI
By the time of the DSM-5 revision, multiple implementation questions had arisen re-
garding the operationalization of the OCF. These included questions about the con-
texts of its use, the length and content of the interview, and the training required to
learn to administer it. The CFI development group came up with suggested solutions
for these questions, as described in the three subsections that follow. Although these
solutions are useful, they are based on expert consensus rather than research data.
More empirical research and clinical experience are needed to clarify many of the fol-
lowing implementation issues.
Contexts of Use
Obstacles to wider use of the OCF have included the lack of detail on when, where,
and how culturally focused assessment should be used, including for which patients,
for what purposes, by which staff members, and at which point in the course of clin-
ical care (Cuéllar and Paniagua 2000). There are differing opinions, which may reflect
different contexts of practice. For example, Jadhav (2010a, 2010b), working in an in-
patient setting in the United Kingdom, recommended using the OCF to engage all pa-
tients. Caballero-Martínez (2009) has suggested reserving the OCF for patients whose
presentation includes cultural content unfamiliar to the clinician. It is also necessary
to clarify what roles the OCF can play in ongoing treatment beyond the initial evalu-
ation (Lewis-Fernández 2009). Additionally, whereas most published case studies

have featured patients from cultural backgrounds unfamiliar to the treating clinician,
such as immigrants or ethnic minorities, some have also included reports of culturally
similar patients and clinicians, illustrating how the OCF can be used to clarify intra-
cultural issues (Aggarwal 2010a).
Guidance is also needed on the clinical training and skills needed to conduct cul-
tural assessment and produce a cultural formulation. In most published case reports,
the treating clinician was the interviewer. However, the OCF may also be used by
nonmedical cultural experts attached to the clinical team, such as a culture broker or
anthropologist (Kirmayer et al. 2008b; Rohlof et al. 2009) who may prepare a report
based on OCF data that can be integrated with routine clinical findings. In Montreal’s
CCS, both clinicians and nonmedical culture brokers found the OCF to be useful, and
psychologists tended to find it more useful than did physicians (Kirmayer et al.
2008b). Dinh et al. (2012) showed that the OCF changed the dynamics of a multidis-
ciplinary group by increasing the participation of nonmedical professionals (e.g., so-
cial workers and others) who could contribute to understanding the patient’s social
world. Assigning the task of cultural assessment to specialized experts may enhance
the cultural information gathered but poses challenges for integrating the formula-
tion into clinical care.
Views differed about whether or not OCF-based questions should be integrated
into routine clinical assessment. Some authors suggested that the assessing clinician
could incorporate portions of the OCF into the clinical evaluation—for example, by
including questions about the history of the present illness in the domain of cultural
explanations of the individual’s illness (Aggarwal 2010b; Caballero-Martínez 2009;
Jadhav 2010a). This approach may encourage attention to this aspect of the OCF with-
out a full interview for every patient. To ensure comprehensive assessment of com-
plex cases, the Montreal CCS conducts a combined clinical-cultural assessment over
one to three visits that include the patient as well as key people in his or her social
network (Kirmayer et al. 2003). Other clinicians in refugee clinics in Sweden and the
Netherlands conduct supplementary interviews after the intake assessment (Bäärn-
hielm and Scarpinati Rosso 2009; Rohlof et al. 2009).
Although cultural formulation is potentially relevant and useful for any patient,
the DSM-5 OCF group identified five main situations in which assessment of cultural
factors may be especially relevant for patient care: 1) when the clinician’s unfamiliar-
ity with the patient’s culture leads to difficulties in diagnostic assessment, 2) when
the clinician is uncertain about how diagnostic criteria fit with the patient’s symp-
toms, 3) when the clinician is having difficulties judging illness severity or impair-
ment, 4) when the patient and clinician disagree about the appropriate course of care,
and 5) when the patient demonstrates limited treatment adherence and engagement
(American Psychiatric Association 2013). Future work will likely identify other situ-
ations in which the CFI can be useful.
Length and Content

The lengths of the various OCF interviews, questionnaires, and protocols described
in Table 1–1 vary from 30 to 90 minutes. The practical dilemma is how to balance brev-
ity with sufficient depth. Kirmayer et al. (2008b) found that 27% of clinicians working
with the CCS felt that the interview failed to assess important information and 30%
found it too lengthy. The lengths of cultural assessment interviews vary widely based
on the complexity of the cases; for example, complicated migration history and past
illness experience take longer to review.
The literature is divided on which section(s) of existing interviews could be short-
ened or eliminated. A study of patients referred for cultural consultation found that
the OCF domain cultural explanations of the individual’s illness contributed less to
final formulations than did other domains, including psychosocial environment, cul-
tural identity, and clinician-patient relationship. This might be because systemic is-
sues are most important but also because many patients have several concurrent
models of illness and are reluctant to offer views that diverge from what they believe
the clinician expects (Kirmayer et al. 2003), a finding replicated elsewhere (Bäärn-
hielm and Scarpinati Rosso 2009). Rohlof et al. (2009) suggested that the domain cul-
tural elements of the relationship between the individual and the clinician could be
subsumed elsewhere. Others, however, supported an elaboration of this section to es-
tablish rapport, promote engagement, and uncover information around cultural fac-
tors related to psychosocial environment and levels of functioning, such as
discrimination and acculturation (Jadhav 2010a, 2010b). As mentioned earlier in this
section, these differing suggestions may reflect the diverse clinical settings and cul-
tural contexts in which the OCF has been used and suggest the need for flexible ap-
plication in both the order of presentation and the depth of elaboration.
Training
Developing a standard training protocol is a necessary step in the large-scale implemen-
tation of any intervention, including assessment interviews such as the CFI. Typically, a
training protocol consists of reviewing written guidelines with clinicians and answering
any questions, observing the intervention through a video demonstration, and practicing
the intervention through case-based simulations. Live supervision or review of video-
taped interviews can be used to ensure that trainees are able to apply the interview pro-
tocol as intended. As measurement-based care becomes more widespread, CFI
implementation may be assessed through instruments that rate fidelity of use after train-
ing, a topic covered within Chapter 4 (see discussion in “Planning and Assessment”).
The DSM-5 CFI has several of the elements needed to develop a standard training
protocol. The sample interview questions in the core CFI and CFI-Informant Version
are accompanied by guidelines indicating the rationale and goal for each item, which
can be reviewed by clinicians. Video simulations similar to those developed for the
DSM-5 field trial of the CFI have been prepared for this handbook (see “Video
Guide”) and for a training video in collaboration with the New York State public
mental health system (the availability of this video will be posted on the Web site of
the New York State Center of Excellence for Cultural Competence at www.nyspi.org/
culturalcompetence). The Psychiatry Milestone Project, a joint endeavor of the Ac-
creditation Council for Graduate Medical Education and the American Board of Psy-
chiatry and Neurology, requires psychiatry residents to evaluate cultural factors in

psychiatric formulation and differential diagnosis, patient development across the
life span, knowledge of psychopathology, and clinical ethics. The CFI may address
these needs, and future work could investigate the reception of CFI training by resi-
dency directors, course leaders, and trainees; the challenges of including the CFI
within the curriculum; and the extent to which trainees use the CFI after graduation.
The development of training videos and evaluation materials would help residency
directors and service administrators assess clinician skill in using the CFI. Training
models in cultural psychiatry aimed at medical students and residents illustrate how
to teach the OCF, including didactic review and journal club discussion of OCF do-
mains, case illustration by preceptors, and supervised case formulation and class pre-
sentations by trainees; these approaches are sometimes combined with experiential
learning (e.g., community visits), cultural self-reflection exercises, and basic ethno-
graphic techniques (e.g., simple field notes), especially by preceptors cross-trained in
the social sciences (Hansen et al. 2013; Kirmayer et al. 2012). These OCF-focused
methods may help guide CFI training and are described in Chapter 5 (“Cultural Com-
petence in Psychiatric Education Using the Cultural Formulation Interview”). The
same approaches can be extended to continuing education and in-service training for
multidisciplinary teams to ensure adequate training of current practitioners.
Conclusion
The OCF in DSM-IV generated substantial international interest as a potential way of
improving the cultural validity of diagnosis and treatment planning. With the devel-
opment of the CFI in DSM-5, the considerations of culture and context introduced in
DSM-IV have been greatly expanded. The literature reviews conducted for DSM-5
and the experience of the DCCIS supported the value of the OCF framework and
guided the design of the CFI as a tool for facilitating cultural aspects of assessment
and treatment planning in clinical practice.
The challenge faced in developing the CFI was how to increase the use of the OCF
by shortening the assessment process so that it is practical in busy clinical settings
while still eliciting crucial information about what is at stake for the patient and pro-
moting the dialogue necessary for person-centered care (Kleinman and Benson 2006).
The contextual understanding facilitated by the OCF is a complement to the decon-
textualized, criteria-based diagnostic assessment that is the focus of much of DSM. To
follow the OCF, clinicians must more thoroughly assess the sociocultural context of
patients’ illness experience. Without this systematic contextual assessment, the mean-
ing of patients’ illness behavior and experience—including accurate calibration of
their symptom severity, stressors, and level of functioning—may elude the practi-
tioner, increasing the risk of clinical mismanagement and of patient dissatisfaction,
nonadherence, and poor treatment response. The ways in which the CFI attempts to
strike a balance between depth and concision in clinical assessment are described in
Chapter 2 (“The Core and Informant Cultural Formulation Interviews in DSM-5”).
KEY CLINICAL POINTS

• The DSM-IV Outline for Cultural Formulation (OCF) provides a conceptual frame-
work for the topics that should be included in a cultural assessment during a men-
tal health evaluation to improve diagnostic accuracy and patient engagement in
treatment planning.
• Implementation gaps hindering widespread adoption of the OCF have included
limited guidance on how to turn the OCF conceptual framework into an interview
for use with patients; lack of guidelines on when, with whom, and why to implement
the OCF; need for adaptation for use with certain populations (e.g., children); and
missing topics useful in practice (e.g., barriers to treatment access).
• The DSM-5 Cultural Formulation Interview (CFI) was developed to help bridge
these implementation gaps.
• The CFI is composed of three parts: a core 16-item questionnaire, an informant
version of the core CFI to obtain collateral information from close associates of the
patient, including caregivers, and 12 supplementary modules that expand on these
basic assessments.
• The four domains of the OCF were included in the development of the CFI, which
also addressed several implementation barriers identified in research and clinical
practice with the OCF since 1994.
Questions
1. What are the four domains of the OCF?
2. To what extent has the OCF been taken up by clinicians and mental health ed-
ucators?
3. What evidence exists on the clinical utility of the OCF?
4. What are some of the clinically relevant features assessed by each domain of
the OCF?
5. Which implementation barriers were addressed in the development of the CFI?
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CHAPTER 2
The Core and Informant

Interviews in DSM-5
Ladson Hinton, M.D.
In this chapter, we introduce the DSM-5 (American Psychiatric Association

2013) core Cultural Formulation Interview (CFI) and the CFI–Informant Version. We
begin with a theoretical description of the core CFI. The CFI comprises three tools for
clinicians to complete a cultural assessment: 1) the core CFI of 16 questions with asso-
ciated prompts for direct patient interviewing; 2) the CFI–Informant Version that can
be administered to close associates of the patient, such as family, friends, caregivers,
and other social supports; and 3) the 12 CFI supplementary modules that expand the
number of questions by cultural domain or include topics of additional interest for cer-
tain populations. All of these tools share a common theoretical foundation, and our
aim in this chapter is to describe this foundation through detailed descriptions of the
core CFI and the CFI–Informant Version; Chapter 3 (“Supplementary Modules”) cov-
ers the supplementary modules in greater depth.
In addition, in this chapter we review key findings from the DSM-5 field trial that
tested an earlier version of the core CFI consisting of 14 items. The field trial results
were taken into account in the final revised core CFI that is included in DSM-5. More
27
details on field trial recruitment, inclusion and exclusion criteria, assessment instru-
ments, and analytical strategies can be found elsewhere (Aggarwal et al. 2013; Lewis-
Fernández and Aggarwal 2013). Here, we focus on three themes that may convince
clinicians and administrators to implement the CFI: 1) its feasibility, acceptability, and
perceived clinical utility as reported by patients and clinicians (Lewis-Fernández et
al., Feasibility, acceptability and clinical utility of the core Cultural Formulation Inter-
view: Results from the international DSM-5 field trial, manuscript in preparation,
March 2015); 2) its beneficial effects on patient-clinician communication (Aggarwal et
al. 2015); and 3) suggestions for overcoming barriers to implementing the CFI in clin-
ical practice (Aggarwal et al. 2013). Clinicians are more likely to implement interven-
tions with a robust evidence base than interventions without such empirical support
(Aarons 2004; Damschroder et al. 2009), and we hope to make the case here that the
CFI possesses a strong and expanding evidence base.
Development of the CFI

The three components of the CFI were developed by the DSM-5 Cross-Cultural Issues
Subgroup (DCCIS) based on a review of the scientific literature since the publication
of the Outline for Cultural Formulation (OCF) in DSM-IV (American Psychiatric As-
sociation 1994) and previous attempts to operationalize the OCF by researchers
around the world, many of whom also served on the DCCIS (Bäärnhielm and Scarpi-
nati Rosso 2009; Groen 2009; Kirmayer et al. 2014; Lewis-Fernández et al. 2014; Mez-
zich et al. 2009; Østerskov 2011; Rohlof 2008; Rohlof et al. 2002; van Dijk et al. 2012).
Mental health professionals have long recognized the need to conduct accurate cul-
tural assessments of patients to prevent misdiagnosis and promote treatment engage-
ment. However, as explained in Chapter 1 (“Cultural Formulation Before DSM-5”),
there have been many ways to conduct such assessments, and few have attempted to
analyze their similarities and differences or harmonize their content. The CFI was de-
veloped as a consensus approach to guide clinicians in how to obtain the information
requested by the OCF directly from patients and members of their entourage. Con-
ceptual and practical problems in the use of the OCF that could benefit from further
attention were identified through the DCCIS literature review and discussed in com-
mittee meetings. In the case of the core CFI, this resulted in an initial draft to be tested
in the DSM-5 field trial (Lewis-Fernández et al. 2014). The process of conducting a
comprehensive literature review to identify areas for revision, with revisions tested
systematically in a field trial with human subjects, has been the revision process for
DSM-5 (Kraemer et al. 2010; Kupfer et al. 2002). Owing to time and financial con-
straints, the CFI–Informant Version and the supplementary modules were not in-
cluded in the field trial.
The core CFI consists of 16 questions with associated instructions for clinicians to
use in conducting a patient-centered cultural assessment. The DCCIS also recom-
mended that all clinicians begin every standard clinical assessment with the core CFI.
This tool has been designed for use with patients of all diagnoses and in all inpatient,
outpatient, emergency, and transitional settings. This broad approach acknowledges
that all patients and clinicians come from cultural backgrounds that can affect clinical
The Core and Informant Cultural Formulation Interviews in DSM-5 29
care, rather than assuming that culture is only a pertinent factor in the care of racial
and ethnic minorities (Aggarwal 2010; Kleinman and Benson 2006). Instructions for
the core CFI have therefore addressed the gap in implementation guidelines for cul-
tural assessments in general and for the OCF in particular.
The DCCIS also deliberated over the order of questions in the core CFI. Several
cultural domains of the DSM-IV OCF had been criticized for being too indistinct and
overlapping (Ton and Lim 2008), often leading to redundant information (Caballero-
Martínez 2009). It was unclear whether clinicians were to obtain information under
these domains in the specific order listed in the OCF. DCCIS members decided to re-
organize the OCF domains to facilitate use of the core CFI at the beginning of every
clinical assessment. For example, whereas the OCF starts with consideration of the
patient’s cultural identity, the core CFI initiates the assessment with the cultural ele-
ments of the patient’s and social network’s definition of the clinical problem. This
parallels a routine mental health evaluation, in which establishing the patient’s pre-
sented complaint helps the clinician organize the rest of the interview. Patients may
otherwise find it odd to lead off with questions about their cultural identity prior to
an assessment of the current problems that cause them to seek care. Appendix A pre-
sents the core CFI that appears in DSM-5 and is based on revisions from the version
used in the field trial.
The core CFI is intended to obtain cultural views and practices in a patient-centered
way. For example, the introduction to the core CFI reiterates that “there are no right or
wrong answers.” This acknowledgment emphasizes that the patient has a right to nar-
rate his or her illness experience. This introduction also affirms that the patient’s un-
derstanding of illness may differ from the clinician’s biomedical understanding of the
disease process (Eisenberg 1977).
Content of the Core CFI

The core CFI is divided into four main domains. The first domain, “Cultural Defini-
tion of the Problem,” consists of the first three questions. Question 1 is meant to be a
broad and open-ended inquiry about the patient’s presenting concerns. The prompt
invites the patient to describe his or her problems and emphasizes an understanding
of the patient’s illness narrative (Kleinman 1988), even if these descriptions are “sim-
ilar to or different from how doctors describe the problem.” Question 2 seeks to clar-
ify further the patient’s description of the problem as he or she would discuss it with
close associates such as family or friends, a recognition that culture can influence how
information is shared differentially depending on audience and social context (Kir-
mayer 2006). At this early point in the interview, patients may be reticent to describe
the problem in ways that the clinician might find unusual and therefore may con-
sciously or inadvertently censor nonmedical descriptions. By framing the question in
relation to the person’s social network, the goal is to facilitate the patient’s report of
as wide a range of descriptions of the situation as is salient in his or her immediate
social environment. Question 3, which asks what troubles the patient most about the
problem, is designed to explore what is most at stake for the individual during the
illness experience (Kleinman and Benson 2006).
Questions 4–10 are grouped in the second core CFI domain, “Cultural Perceptions
of Cause, Context, and Support.” Questions 4, 6, and 7 focus the interview on the pa-
tient’s explanatory models regarding the causes of the problem (Kleinman 1980;
Kleinman et al. 1978), social supports that make the problem better, and social stress-
ors that contribute to the problem (Mezzich et al. 2009). Question 4 includes the place-
holder “[PROBLEM],” which is designed to solicit the patient’s own terms and
phrases for how a problem is framed in the clinical setting—these are known as idioms
of distress (Nichter 1981). The interviewer can then substitute the patient’s vocabulary
for the placeholder throughout the interview, which helps to build rapport and
bridge linguistic differences in patient and clinician understandings of illness. In
some cases, the patient might use biomedical vocabulary, such as when a patient says,
“I might have depression.” In other cases, the patient might use a more psychosocial
description, such as “I worry about my rent, my electricity, my phone bill.” Terms that
communicate the problem presented may vary greatly, and the CFI can reveal how
patients frame issues so that clinicians can tailor treatment strategies most effectively.
Additionally, question 5 asks the patient to consider what friends, family, and
close associates might understand as the cause of illness; this question is included to
explore one understanding of culture—that is, as the meanings and viewpoints trans-
mitted within social groups (American Psychiatric Association 2013). In this instance,
the meanings being transmitted are the understandings of illness, and the social
group is the patient’s network of close associates. As with question 2 on the definition
of the problem, framing the inquiry in terms of the social network encourages pa-
tients to report a fuller range of explanations in their social environment that may be
influencing their explanatory models. For example, in video 1, Full CFI, that accom-
panies this book, when asked about her “inability to relate to others,” the patient an-
swers, “They just don’t understand what’s going on. . . . They just think that I’m
crazy.” This information suggests that the patient’s presented problem is not cultur-
ally normative within her social network.
Video Illustration 1: Full CFI (6:57)
One understanding of culture in DSM-5 is “the influence of family, friends, and

other community members (the individual’s social network) on the individual’s
illness experience” (p. 750). The relationship between the individual and her
social network is on display in the video illustrating use of the core CFI, which
includes segments of a full CFI evaluation. The video begins with the inter-
viewer asking the open-ended, first question, “What brings you here today?”
The woman also responds in an open-ended manner, discussing concerns
about starting college as context before conveying that she hears the voice of
her deceased grandmother. “She keeps telling me to go to Panama and just
start my life over,” the woman says. The interviewer continues by asking how
the patient would describe the problem to others in her social network, and the
patient answers that she cannot discuss this problem with them. In response to
what troubles her most about the problem, she says, “Nobody is taking me se-
riously.” Just from these initial questions, we learn that the patient experiences
significant distance from her social network with respect to her problem.
Next, the interviewer transitions into questions about the patient’s explana-
tions for her current experiences. In responding to a question on associated
stressors, she says, “Now I have the answer that I need. My grandmother is
telling me what I need to do.... I guess what’s stressing me out now is I need
to figure out how to get to Panama.” Here the CFI assists the clinician in inter-
preting degrees of social impairment.
Afterward, the CFI questions on identity invite the patient to share experiences
about her background. In response to a question about how her background or
identity relates to the problem, the patient answers that she used to be close to
her family and specifically names her brothers and grandmother. When con-
sidered in relation to earlier answers, we learn that hearing her grandmother’s
voice may contribute to her present sense of estrangement from her family. No-
tably, the family unit is central to her sense of self and its relationship to the
problem she presents. Despite being a woman of Panamanian background, she
does not identify gender, ethnicity, or geographical origin as the social groups
that most influence her illness experience. These markers of background and
identity may be important in other situations but do not seem pertinent in this
health care setting. Therefore, the CFI is able to clarify that the family unit is the
group she regards as most clinically relevant.
Finally, the interviewer asks about the patient’s past and present forms of cop-
ing and help seeking. We learn that the patient has tried to write as a form of
self-coping upon encouragement from others, but this has not been particu-
larly successful. She has also sought help from her family, who, in turn, have
said, “Go talk to a therapist.” The examiner asks about barriers to care, and the
patient answers, “Everyone ...Nobody understands what is happening.... I
can’t trust anybody.” She remains focused on moving to Panama and obeying
the wishes of her grandmother in response to what would best help her now.
“The people that I tried to confide in don’t understand me.... I need someone
who will take me seriously.” Interpersonal problems appear to distress her, and
the CFI has now uncovered two clinical problems that could be addressed in
the future: 1) her relationship to her social network and 2) hearing the voice of
her deceased grandmother. A standard interview could also provide informa-
tion on hearing voices, but it is unlikely that details about the social network
would be obtained unless an extensive social history was obtained. With this
foundation, the clinician can use the CFI supplementary module on the social
network with the patient or the CFI–Informant Version with key members
from the patient’s social network—with patient consent—to better understand
their perspectives.
Questions 8, 9, and 10 also belong to this second domain, but they orient the inter-
view toward the patient’s cultural identity. Question 8 is preceded by a brief introduc-
tion that clinicians can use to clarify the meaning of cultural background or identity as
relevant to the health care context. The introduction also provides examples of iden-
tities that may be important for the patient, such as language, ethnicity, religion, and
sexual orientation. Question 8 then asks the patient directly about the most important
aspects of background or identity. This method of allowing the patient to name his or
her cultural identity departs from previous models of cultural competence that have
often made assumptions about patient identities based on a group affiliation such as
race or ethnicity without accounting for their importance to the individual (Aggarwal
2012). For example, one patient in the field trial initially named his identity as Cuban
but then explained that identifying as a Christian was more helpful in understanding
his suffering existentially. In his case, a model of cultural competence that assumed
ethnicity was the patient’s most important group affiliation—without accounting for
his self-ascribed identity—might have overlooked the role of religion in providing
meaning to the illness experience. Question 9 then asks the patient how this identity
may impact the current illness experience, predicament, or other patient-centered
definition of the clinical problem. Question 10 asks the patient to consider how iden-
tity may cause other problems throughout life that may not initially come to mind as
related to the illness but may, nonetheless, be important for clinicians to understand,
such as problems with migration, gender roles, or intergenerational conflict.
Questions 11, 12, and 13 form the third domain, “Cultural Factors Affecting Self-
Coping and Past Help Seeking.” The goal of this domain is to encourage patients to
share past forms of self-coping and help seeking, a recognition that most forms of
help are sought outside of the biomedical health care system (Rogler and Cortés
1993). Question 11 addresses the patient’s coping practices, and question 12 considers
help seeking broadly, to include help within and outside of the biomedical system
(e.g., religion-based support, support groups). One patient, for example, mentioned
that going to church meetings that were specifically tailored to his age group pro-
vided the most comfort during exacerbations of auditory hallucinations. An addi-
tional prompt for question 12 clarifies the types of help that have been most and least
helpful. This information may aid the clinician in developing a treatment plan for the
current illness episode. Question 13 asks about past barriers to treatment. This infor-
mation may also prove useful in devising the current treatment plan around available
resources.
The final three questions of the CFI constitute the last domain, “Cultural Factors
Affecting Current Help Seeking.” Question 14 asks the patient about current treat-
ment preferences, and question 15 explores treatment preferences that may be ex-
pressed by close associates. As with the questions on patient terms for illness or other
self-definitions of the clinical situation, and their causes, this question on treatment
preferences is examined at the individual and social levels. Finally, question 16 is pre-
ceded by an open-ended statement for the patient to anticipate how any perceived
differences with the clinician can adversely affect care. By asking the patient directly
about this potential barrier, the clinician can validate patient concerns and work to re-
solve such differences. Even if the question is not answered directly during the initial
visit, the clinician’s openness to the topic may empower the patient to raise concerns
about the patient-clinician relationship later in the treatment.
In summary, the core CFI adopts an ecological approach to culture by first asking
the patient about the illness, moving outward to the role of social supports and stress-
ors, and then finishing broadly with the illness in relation to the health care system.
Development of the CFI–Informant Version

The purpose of the CFI–Informant Version is to assist clinicians in conducting a cul-
tural assessment of the presenting clinical problem from the perspective of a key in-
formant, such as a spouse, other family member, or friend who may be present during
the clinical encounter. Patients are often accompanied by family or other potential in-
formants during clinic visits, providing clinicians with the opportunity to include
these close associates in the process of psychiatric diagnosis and treatment planning.
The mental health literature has documented the many ways that social relationships
can have profound effects—both positive and negative—on pathways to and through
mental health treatment, including decisions about when or whether to seek care,
participation in clinic visits, and implementation of treatment plans in the home, in-
cluding adherence to medication (Jenkins and Karno 1992; Lefley 1996). As men-
tioned in the section “Development of the CFI,” the expected roles of close associates
and these individuals’ perspectives on illness and treatment are rooted in culture. In
this section, we describe the rationale for the CFI–Informant Version, clinical situa-
tions when this version may be useful, and issues for the clinician to anticipate when
using the CFI–Informant Version in clinical practice. We do not explain each question
of the CFI–Informant Version because it shares the same theoretical basis as the core
CFI. The CFI–Informant Version is reproduced in Appendix B.
To be most effective, psychiatric diagnosis and treatment planning often require
consultation with relatives or friends of individuals with mental illness. Certain as-
pects of culture may be shared among patients and others within the social network,
but there may be important and unexpected differences even within families. For ex-
ample, an older Vietnamese man who is depressed and most comfortable speaking
Vietnamese may be accompanied by an adult child who speaks English and has
adopted Anglo-European cultural values. In such cases, the patient and the infor-
mant may have quite different explanatory models for the patient’s depression or
view of treatment. In such situations, the CFI–Informant Version can assist in elicit-
ing the cultural perspectives of key informants, enabling a deeper understanding of
the patient’s illness and the interpersonal dimensions of care. These varieties of per-
spective can open up opportunities for negotiation and the development of shared
understandings of illness and goals for treatment.
After the decision has been made to conduct a cultural assessment, administration
of the CFI–Informant Version can play an important role in clinical care in several
types of clinical situations when an informant is available. In some instances, the in-
formant may be the primary or sole source of information that is needed to assess the
role of cultural factors in psychiatric diagnosis and treatment. This may occur, for ex-
ample, when the clinician is assessing someone who is not able to give a meaningful
or coherent history because of conditions such as severe cognitive impairment (e.g.,
due to a neurodegenerative brain process such as Alzheimer’s disease or a head in-
jury), catatonia, severe paranoia, or agitation. Similarly, if the patient is a young child,
it may be necessary to conduct a cultural assessment of the parent’s or another care-
giver’s perspective. In other cases, the clinician may seek clarification from the infor-
mant when the patient’s responses to the CFI are ambiguous or partial (e.g., when
asking the patient about how others in his or her cultural group would view the
symptoms). The clinician may also choose to administer the CFI–Informant Version
if there is an identified family member or friend who is perceived to be influential and
active in the patient’s clinical care and decision making. In certain situations, deci-
sions about care may reside fully with a family member or other significant person in
the patient’s life. In these situations, conducting a cultural assessment of the infor-
mant’s perspective may help to negotiate and implement a treatment plan. Finally,
the CFI–Informant Version may be useful when treatment hits an impasse and a fuller
assessment of the social context may identify underlying causes. The following is a
summary of the types of clinical situations in which use of the CFI–Informant Version
may be helpful: 1) the patient is unable to give a coherent account of illness (e.g., be-
cause of significant cognitive impairment); 2) the patient’s history is vague, contra-
dictory, or ambiguous, and collateral information would be beneficial for
clarification; 3) the informant plays a significant role in health care decision making
and/or caregiving; 4) the patient has a strong preference for including the family
member in the cultural assessment (e.g., for cultural or other reasons); and 5) diag-
nostic or treatment challenges emerge later in the course of treatment, and additional
collateral information may be useful.
In choosing whether to use the CFI–Informant Version, the clinician should pon-
der several issues. Initially, it is critical for the clinician to discuss the involvement of
an informant with the patient and to respect the patient’s desire for autonomy and
privacy. Patients may have many different reasons for not wanting a family member
involved, including concerns about burdening family members, shame about certain
aspects of the problem, or discomfort with discussing conflicts with the informant
that are contributing to the patient’s problem. In these situations, the clinician may
need to negotiate family involvement over time, after the patient and clinician have
established rapport. In other situations, such as when the patient insists on having
family members present during the clinical encounter and defers to them, the clini-
cian may need to negotiate time during the visit to meet individually with the patient
to provide an opportunity for sensitive issues to be discussed that might involve fam-
ily members (e.g., conflict, abuse). After the informant interview, the clinician may
need to decide whether to reinterview the family member (or other informant) in the
presence of the patient and vice versa. Ultimately, this decision should be based on
the preferences of the patient.
A related issue is that the clinician may find important differences between the
views of patients and informants (e.g., in their illness explanatory models or in the ex-
tent to which behavior is viewed as normative for their cultural group). One possible
approach to such situations is to present the different perspectives in a nonjudgmen-
tal way, together with the biomedical view of illness, and then to try to negotiate a
partially shared understanding of illness and treatment (Hinton and Kleinman 1993).
When multiple perspectives cannot be resolved in this way, at least documenting the
differences may assist the clinician in seeking additional information to clarify diag-
nostic issues or help in anticipating obstacles to implementing the treatment plan.
It is also essential to note that the clinician has flexibility in the timing and admin-
istration of the CFI–Informant Version. For example, the clinician can decide whether
to use the Informant Version at the initial visit or later in the course of treatment. In
addition, the clinician may choose to use all of the Informant Version or only the part
that seems most relevant to clinical care. Third, in situations with multiple family
members or caregivers, the clinician needs to make pragmatic decisions about whom
to interview based on patient preference as well as the informant’s knowledge of the
patient and the extent to which he or she is involved in day-to-day caregiving. Finally,
the supplementary modules may be useful in conjunction with the CFI–Informant
Version, particularly the Caregivers supplementary module, which explores in greater
depth the role of cultural factors in the experience and enactment of caregiving.
Key Findings From the DSM-5 Field Trial

Having introduced the core CFI and the CFI–Informant Version, we now turn to find-
ings from the international DSM-5 field trial. The field trial tested an earlier version
of the core CFI, and data analyses conducted midway led to the revision of the core
CFI that is now included in DSM-5. We briefly present an overview of the study de-
sign to help clinicians contextualize key results.
Overview
The international composition of the DCCIS allowed us to expand the scope of the
DSM-5 field trials beyond the United States. Between 2011 and 2012, field trials were
conducted in 14 sites across six countries (5 in the United States, 1 in Peru, 2 in Can-
ada, 3 in the Netherlands, 1 in Kenya, and 2 in India). Table 2–1 lists all participating
sites by country, along with local primary investigators.
Apart from the three clinics in the Netherlands that agreed to act as a single con-
sortium site, all other individual sites sought to enroll at least 30 patients and five cli-
nicians to test the core CFI’s feasibility (Is it doable?), acceptability (Do people like
it?), and perceived clinical utility (Is it helpful?). Patients were recruited by treating
clinicians who made study referrals to research staff at each site. Appreciating that
many clinicians work in busy service settings, the DCCIS created the core CFI so that
it could be completed in 15–20 minutes, reasoning that a full cultural and clinical as-
sessment could be completed within 1 hour. Our assumption was that core CFI ques-
tions would reduce the need to obtain redundant information with respect to the
history of present illness, past psychiatric history, and social history. Clinicians and
patients completed questionnaires before and after the CFI session on experiences
with the core CFI.
Study Participants
Patients ages 18–80 years were enrolled because patients in this age group can directly
provide informed consent. We enrolled patients of any race or ethnicity in recognition
that all people—not only individuals from racial and ethnic minority groups—have a cul-
ture. To reduce any bias arising from cultural information obtained by interpreters, all pa-
tients and clinicians were matched by language. Patients with all psychiatric diagnoses
were enrolled, and these psychiatric diagnoses were determined by referring clinicians.
TABLE 2–1. All participating sites by country in the DSM-5 core Cultural
Formulation Interview field trial
Country Local institutions (site investigators)
Canada McGill University (Laurence Kirmayer)

University of Toronto (Monica Scalco)
India Dr. Ram Manohar Lohia Hospital (Smita Deshpande and Sushrut Jadhav)
KEM Hospital Research Centre (Vasudeo Paralikar and Mitchell Weiss)
Kenya University of Nairobi (David Ndetei)
Netherlands Centrum ‘45 (Hans Rohlof)
De Evenaar Centre for Transcultural Psychiatry North Netherlands (Simon
Groen)
Parnassia Bavo Groep (Rob van Dijk)
Peru Universidad Peruana Cayetano Heredia (Renato Alarcón and Johann Vega-
Dienstmaier)
United States Columbia University and the New York State Psychiatric Institute (Roberto
Lewis-Fernández and Neil Krishan Aggarwal)
Richmond Area Multi-Services (Kavoos Bassiri)
University of California–Davis (Sergio Aguilar-Gaxiola and Oanh Meyer)
University of Minnesota (Joseph Westermeyer)
Yale University (Esperanza Díaz)
We excluded patients who were acutely suicidal or homicidal at the time of the interview
for safety reasons, as well as patients with conditions that could interfere with the inter-
view process (e.g., acute substance intoxication or withdrawal, dementia, florid psycho-
sis, mental retardation). As with other DSM-5 field trials that tested new diagnoses or
revisions to diagnoses from DSM-IV, all patients and clinicians who volunteered were en-
rolled (Clarke et al. 2013). A total of 314 patients were included.
All clinicians in the field trial were already on staff at each site and possessed a
terminal degree (MD, MSW, PhD, or a local equivalent) that allowed them to practice
independently. Clinicians accepted into the field trial had to agree to attend a 2-hour
training session on the core CFI. During the session, the core CFI and its guidelines
were reviewed, a video was shown of the core CFI in a simulated scenario, and role-
playing exercises were conducted in which clinicians practiced questions with each
other. All clinicians were asked to complete the core CFI in its entirety before transi-
tioning into their usual diagnostic assessment. Interviews were recorded only with
patient and clinician consent. A total of 75 clinicians were included.
Main Results
Feasibility, Acceptability, and Perceived Clinical Utility of the Core CFI
Patients and clinicians completed surveys on their perceptions of the feasibility, ac-
ceptability, and clinical utility of the core CFI after every encounter. Items were scored
TABLE 2–2. Feasibility, acceptability, and clinical utility subscores by

patients and clinicians participating in field trial
Patients Clinicians
Mean Standard deviation Mean Standard deviation
Feasibility 1.33 0.57 0.77 0.89

Acceptability 1.27 0.71 1.01 0.72
Clinical utility 1.30 0.52 0.93 0.72
Note. Numerical range from which patients and clinicians chose scores for feasibility, acceptability, and
clinical utility: –2=strongly disagree; –1=disagree; 1=agree; 2=strongly agree.
on a four-point scale: –2 (strongly disagree), –1 (disagree), 1 (agree), and 2 (strongly

agree). Scores on the negative half of the scale indicated greater disagreement with
the core CFI as feasible, acceptable, or clinically useful, whereas positive scores indi-
cated greater agreement on those factors. We assessed feasibility, acceptability, and
perceived clinical utility as separate subscales.
Although survey length and wording differed between the patient and clinician
versions, the fundamental concepts ascertained by the survey subscales were consid-
ered comparable. Psychometric analyses were performed on the survey subscales to
generate Cronbach , as a measure of internal consistency (Cronbach 1951). For the
clinician version of the subscales, these analyses showed adequate internal consis-
tency: feasibility =0.77, acceptability =0.78, and clinical utility =0.89. For the pa-
tient version of the survey, removal of one negatively worded item from the feasibility
and acceptability subscales that demonstrated poor correlation with the rest of the
subscale items led to acceptable internal consistency: feasibility =0.45 and accept-
ability =0.46. The patient clinical utility subscale scores demonstrated good internal
consistency (=0.82), and no item was removed from this subscale for analytical pur-
poses. These data suggest that the scales created for the DSM-5 field trial had ade-
quate to good internal consistency.
Table 2–2 lists the mean scores and standard deviations of these final subscales for
patients and clinicians. Patients generally rated each construct with higher scores
than did clinicians, but both groups appear to appreciate the core CFI as feasible, ac-
ceptable, and clinically useful (no negative mean values).
CFI’s Effects on Medical Communication
To understand why patients and clinicians reported that the core CFI was feasible, ac-
ceptable, and clinically useful, we analyzed debriefing questionnaires given to all par-
ticipants after the CFI session. Case reports on the OCF have suggested that cultural
questions help clinicians overcome communication barriers and improve patient sat-
isfaction (Groen 2009; Caballero-Martínez 2009). Therefore, we sought to assess clini-
cian and patient perspectives of the core CFI’s effects on medical communication.
A team of three people from the New York State Psychiatric Institute coded all of
the New York interviews to explore how participants believed the core CFI affected
medical communication based on a framework widely used in medical education

(Lazare et al. 1995). This framework suggests that the medical interview has three
main functions: 1) to determine and monitor the problem presented; 2) to develop,
maintain, and conclude the therapeutic relationship; and 3) to carry out patient edu-
cation and implementation of treatment plans. Each task is further divided into spe-
cific tasks. Table 2–3 presents code rankings from patient and clinicians interviews.
Patients and clinicians thought that the main functions of the core CFI were 1) to
determine and monitor the nature of the problem and 2) to develop, maintain, and
conclude the therapeutic relationship. They also responded most positively to four
main tasks within these functions: eliciting data, eliciting the patient’s perspective,
perceiving data at multiple levels, and enhancing rapport through satisfaction with
the interview. We expected high scores for the first two tasks because the core CFI was
created to obtain patient experiences of illness. Our analysis observed fewer themes
for the third function, patient education and implementation of treatment plans. This
may be due to the nature of our study, in which patients and study clinicians met once
in order to test the interview. Patients were not educated about diagnoses, and treat-
ment plans were not implemented.
Our most significant finding was our code for a new theme that did not appear in
the original medical communication framework (Lazare et al. 1995). We defined this
theme as “enhancing patient-clinician rapport through satisfaction with the CFI.” Pa-
tients believed that the core CFI itself possessed communication properties that were
therapeutic, independent of the clinician’s ability to establish rapport. The coding
team included this theme under the function of developing, maintaining, and con-
cluding the therapeutic relationship. These data suggest that the actual structure of
the core CFI may elicit positive communication. The CFI invites patients to partici-
pate actively throughout the clinical encounter via the use of a nonjudgmental intro-
duction, open-ended questions on illness experience, patient-clinician word
matching, and a patient-centered approach to how culture is relevant for the individ-
ual’s illness. We hypothesize that these communication strategies may be responsible
for increased satisfaction, although more studies on patient-clinician communication
exchange through the core CFI are necessary to isolate exact linguistic properties.
More studies are also needed on whether increased patient satisfaction through use
of the core CFI improves overall treatment response, such as symptom reduction or
improvements in quality of life. Nonetheless, these results build the evidence base
that the core CFI may operate successfully at the level of content through the elicita-
tion of patient cultural views and at the level of process through improved patient-
clinician communication.
Barriers to Implementing the Core CFI in Clinical Practice
Finally, we wanted to understand how patients and clinicians reported limitations in
the core CFI’s feasibility, acceptability, and clinical utility. We analyzed the same de-
briefing interviews for problems with the core CFI. We used another framework on
the barriers encountered when new interventions are introduced in clinical settings
(Gearing et al. 2011), which differentiates problems related to the intervention from
problems associated with its implementation. For example, problems related to the
TABLE 2–3. Core Cultural Formulation Interview’s (CFI’s) effects on medical

communication as coded in debriefing interviews
Patient Clinician
ranka ranka
Determining and monitoring the nature of the problem
Diseases and disorders: The CFI helps clinicians make a biomedical diagnosis. 7 7
Psychosocial issues: The CFI illustrates how patients respond to their 9 6
condition before entering medical care.
Eliciting data: The CFI encourages communications skills by letting 2 2
patients tell their own stories, facilitating narration, easing flow of the
interview, using appropriate questions, or summarizing information.
Perceived data at multiple levels: The CFI helps clinicians use their five 4 2
senses and their own personal responses.
Generating and testing hypothesis: The CFI helps clinicians create or test Last 5
hypotheses based on patient data.
Developing, maintaining, and concluding the therapeutic relationship

Defining the relationship: The CFI helps clinicians clarify their exact role 8 8
in the patient’s care.
Communicating expertise: The CFI helps clinicians demonstrate scientific Last 9
competence and wisdom in their judgment and decisions.
Communicating care: The CFI helps clinicians communicate positive 3 4
emotions such as rapport, interest, respect, support, and empathy.
Recognizing communication barriers: The CFI helps clinicians recognize and 5 4
resolve communication problems with patients by openly discussing
differences, overcoming patient psychological barriers, providing emo-
tional support, or negotiating communication differences.
Eliciting the patient’s perspective: The CFI elicits the patient’s perspective on 4 1
definition, causes, mechanisms, fears, and goals related to the problem.
Enhancing rapport through satisfaction with the interview: The CFI 1 3
increases rapport among patients and clinicians.
Patient education and implementation of treatment plans

Determining areas of difference: The CFI helps clarify where patients and 6 5
clinicians may disagree about ideas regarding patient’s sickness.
Communicating diagnostic significance: The CFI helps clinicians commu- Last Last
nicate the significance of the problem from a biomedical perspective,
taking into account the patient’s concerns, beliefs, and fears.
Negotiating diagnostic procedures and treatment: The CFI helps clinicians Last 10
discuss diagnosis and treatment options.
Negotiating preventive measures: The CFI helps clinicians negotiate and Last Last
recommend preventive measures.
Enhancing coping: The CFI helps clinicians work with patients to dis- 8 9
cuss coping strategies related to worsening social and psychological
functioning from the illness or treatment.
Note. aTied rank is based on number of references in all interviews.
Source. Adapted from Aggarwal et al. 2015.
intervention could include its complexity, lack of clarity, and problems with standard-
ization, whereas problems related to organizational or clinician factors could include
frequent clinician turnover, training costs, and difficulties with scheduling that make
implementation difficult. Table 2–4 presents barriers to implementing the core CFI as
reported by patients and clinicians.
Notably, more clinicians than patients reported barriers for each theme, perhaps
because clinicians are responsible for implementation of the CFI. The highest-ranked
barrier reported by clinicians was that they could not see how the core CFI responds
to the need for a cultural assessment. To overcome this barrier, the DCCIS made the
following revisions in the final core CFI version included in DSM-5: defined culture
in the core CFI guidelines, provided specific indications for when a cultural assess-
ment is necessary, and explained the purpose of each question. The second barrier is
lack of motivation based on patient and clinicians responses combined. For example,
the field trial version of the core CFI included a question on the patient-clinician rela-
tionship that troubled some clinicians: “Is there anything about my own background
that might make it difficult for me to understand or help you with your [PROB-
LEM]?” Many clinicians reported that this question was too direct and could lead to
negative emotions such as discomfort or awkwardness. Consequently, this question
was revised to question 16 in the final version of the core CFI: “Sometimes doctors
and patients misunderstand each other because they come from different back-
grounds or have different expectations. Have you been concerned about this and is
there anything that we can do to provide you with the care you need?” With aware-
ness of this reported barrier, the DCCIS was able to improve the core CFI in order to
increase its feasibility, acceptability, and clinical utility.
Three responses tied for the third most-reported barriers to the core CFI. Some cli-
nicians found the field trial version of the core CFI to be too repetitive. This concern
also became apparent for the OCF during the DCCIS systematic literature review
(Lewis-Fernández et al. 2014). Subsequently, the DCCIS revised the core CFI during
the field trial to ensure that cultural topics would be unique and not repetitive. Fi-
nally, some clinicians raised doubts about whether the core CFI could be used in its
entirety during the initial diagnostic assessment and whether certain illnesses such as
psychotic disorders would render the core CFI difficult to use.
Conclusion
In this chapter, we introduced the core CFI, the CFI–Informant Version, and the CFI
evidence base through key findings from the DSM-5 field trial. We hope that clini-
cians and administrators will find the scholarship on the CFI convincing and will at-
tempt its implementation in their service settings (as discussed in Chapter 4, “Clinical
Implementation of the Cultural Formulation Interview”). Research is ongoing on the
best ways to use all three components and the extent to which their use affects illness
outcomes. The CFI represents the state of the art in cultural assessment throughout
the mental health professions. Widespread use of the CFI—especially the core CFI—
by clinicians and administrators is expected to help close the research-practice gap in
cultural assessment and inform the next round of revisions for future DSMs.
The Core and Informant Cultural Formulation Interviews in DSM-5
TABLE 2–4. Barriers to implementing the core Cultural Formulation Interview (CFI) in clinical practice
Patient reported Clinician reported Barrier rank

Theme (n=32) (n=32) (of 64 interviews)
Internal barriers to using the core CFI

Repetition: Parts of the CFI may be too repetitive — 20 3a
Drift in procedures: Doubts about using the CFI in its entirety at the beginning of — 20 3a
the evaluation
Lack of motivation/buy-in: Negative attitudes or emotions regarding the CFI 8 14 2
(such as questions on past illnesses or on religion)
Severity of the individual’s illness: Concerns that the patient’s illness presentation 1 19 3a
would affect CFI implementation
External barriers to using the core CFI

Lack of conceptual relevance between the CFI and culture: Comments that the pur- — 31 1
pose of the CFI or specific questions lacked clarity
Note. Dash indicates none reported.
aThe rankings are based on total references in patient and clinician interviews combined.
Source. Adapted from Aggarwal et al. 2013.
41
KEY CLINICAL POINTS

• The core and informant versions of the Cultural Formulation Interview (CFI) con-
stitute a state-of-the-art cultural assessment in mental health that builds off the ex-
isting evidence base in the social and clinical sciences.
• The core CFI is a semistructured questionnaire of 16 questions that can be used
with all patients to assess relevant cultural variables in every clinical encounter.
The CFI–Informant Version obtains similar information from a collateral historian.
• Patients and clinicians found the core CFI generally to be feasible, acceptable, and
useful for practice. Field trial data were used to revise the core CFI questions for
inclusion in DSM-5.
• The CFI improves medical communication.
Questions
1. How does the DSM-5 CFI differ from the DSM-IV OCF?
2. With what patient populations can the core CFI and CFI–Informant Version be
used?
3. What are some of the core CFI effects on medical communication?
4. What kinds of barriers can be anticipated so that the core CFI is more feasible,
acceptable, and useful in clinical practice?
5. In what clinical settings can the core CFI be used?
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Suggested Readings
Mezzich JE, Caracci G (eds): Cultural Formulation: A Reader for Psychiatric Diagnosis. Lan-
ham, MD, Jason Aronson, 2008. Explains the development of the OCF.
New York State Office of Mental Health, Center of Excellence for Cultural Competence: Cultur-
al Formulation Interview Project, 2013. Available at: http://nyculturalcompetence.org/
research-initiatives/initiative-diagnosis-engagement/cultural-formulation-interview-
project/. Accessed September 15, 2014. A Web site with ongoing research on the Cultural
Formulation Interview.
CHAPTER 3
Supplementary Modules
Overview
Ladson Hinton, M.D.
The main goal of all of the components of the Cultural Formulation Interview
(CFI; American Psychiatric Association 2013) (i.e., the core CFI, the CFI–Informant
Version, and the supplementary modules) is to contextualize the problem that the pa-
tient presents in a complex multidimensional way—within the context of the person’s
sociocultural world, sense of identity, and ways of experiencing and understanding
psychological distress. This ecological examination of the patient helps the clinician to
select the appropriate treatment approach in collaboration with the patient, to enhance
the patient’s engagement in care (from session attendance to medication use), to im-
prove the therapeutic bond, to promote positive expectancy, and to accomplish other
key treatment goals (Hinton and Lewis-Fernández 2010).
To illustrate the value of this approach, we consider the case of a patient with a
main complaint of “being depressed.” The CFI focuses particularly on the patient’s
“illness,” in the sense of a certain lived reality of the experience of suffering. The per-
son is an active agent in dealing with her illness, has a set of understandings about
her experience (including about the contribution of any underlying biomedical “dis-
ease” involving, e.g., abnormally functioning brain circuits), and is embedded in a
particular sociocultural “local world” (Eisenberg 1977; Kleinman et al. 1978). These
various dimensions of experience influence her behavioral strategies and adaptations
to illness and treatment in a way that is directly relevant to clinical care—for example,
45
by shaping her interpretation of the diagnosis and her expectations regarding medi-
cation taking. To neglect these various dimensions is to commit an “error of decontex-
tualization” (Hinton and Good, in press; Weiner et al. 2010), whether these
dimensions include the patient’s understanding of the “problem,” her life situation
(e.g., income, employment), her sense of belonging to a set of social groups (e.g., elder
adults, migrants), or the views about the problem held by others in her social world.
Put another way, neglecting these factors is to commit a dynamism error—that is, the
failure to examine how the patient reacts to and deals with the problem in various
ways as influenced by a certain identity and sociocultural context.
The supplementary modules of the CFI—along with the CFI–Informant Version—
help the clinician conduct a more comprehensive cultural assessment of the patient,
which attempts to locate the person in his or her sociocultural context. As indicated in
Figure 3–1, there are three kinds of supplementary modules: 1) core CFI expansion
modules, to amplify key sections of the core CFI (e.g., the explanatory model); 2) special
populations modules, to assess particular populations (e.g., refugees) who may have
specific needs and experiences as a result of certain aspects of their background or iden-
tity; and 3) informant perspectives modules, to clarify how individuals who assist the
patient with his or her care and members of the patient’s social network view the pa-
tient’s situation. Although the CFI–Informant Version is not strictly one of the 12 sup-
plementary modules, it is included in this listing because it helps the clinician obtain a
fuller picture of the patient’s situation when combined with the core CFI. In this chap-
ter, we discuss the clinical utility, types, and structure of these three types of modules to
help clinicians choose among them when conducting a cultural assessment.
Uses of the Supplementary Modules:

Research, Clinical Work, and Training
The core CFI is a basic tool for cultural assessment, but at times the clinician needs to
use all or some of the supplementary modules to obtain more information. This may
be because the core CFI either does not address certain assessment domains or as-
sesses them too succinctly for the current situation or treatment need or because the
clinician may not wish to administer the full core CFI but to focus, rather, on some of
its domains, either because the core CFI has already been administered or because
only a more limited assessment is currently necessary. For example, the clinician may
wish to use one or more of the core CFI expansion modules to elicit information on
the patient’s understanding of his or her problem and related explanatory model or
to learn more about the person’s experience of, for example, spirituality, religion, and
moral traditions and how they relate to the problem. Alternatively, the clinician may
want to use one or more of the special populations modules because aspects of the
person’s identity (e.g., as an adolescent and immigrant) cause certain questions that
are not part of the core CFI to become relevant. Finally, the clinician may turn to the
informant perspectives modules to clarify the interviewee’s views on the patient’s
problems because the interviewee helps to provide care to the patient or is a key
member of the person’s support system.
Overview
Core Cultural Formulation Interview (CFI)
Core CFI Expansion Modules Special Populations Modules Informant Perspectives Modules
(each one further evaluates an area in the core CFI)
Older Adults Immigrants and

Refugees
School-Age Children
and Adolescents
CFI–Informant Version Caregivers
Explanatory Patient-Clinician (repeats all core CFI (elicits further information
Model Relationship questions with respect to specific to a caregiver)
the patient’s problem but
Level of Coping and is conducted with a person in
the patient’s social network)
Functioning Help Seeking
Social Cultural
Network Identity
Psychosocial Spirituality, Religion,

Stressors and Moral Traditions
FIGURE 3–1. Decision tree showing possible further evaluations using the CFI–Informant Version and the supplementary mod-
ules after giving the core Cultural Formulation Interview.
47
We describe, as an example, how using the modules may improve the care of ref-
ugees or immigrants. The Immigrants and Refugees module would be a logical mod-
ule to administer, but other modules can also become relevant. For example, a person
may belong to an immigrant or refugee group that frequently describes certain mood,
somatic, or other symptoms that may be unfamiliar to the clinician; these can be as-
sessed through the Explanatory Model module and/or the Coping and Help Seeking
module. Specifically, traumatized refugees often present with somatic complaints
(e.g., shortness of breath or trembling among Caribbean Latinos or dizziness among
Chinese and Southeast Asian populations) and can report culturally specific idioms
of distress (e.g., complaints of “nervios” among Latinos or “neurasthenia” among Chi-
nese populations) (Guarnaccia et al. 2003; Hinton and Lewis-Fernández 2011; Klein-
man 1986). Moreover, the Caregivers module might be of great use if an immigrant or
refugee is being cared for by a relative or an informally arranged care provider (e.g.,
a community member who receives compensation from the family). The Psychosocial
Stressors module might also be helpful because of the key role of current life prob-
lems in generating distress (e.g., among traumatized refugees) (Hinton et al. 2011;
Miller and Rasmussen 2010). Other modules can also be useful.
These examples suggest how the 12 supplementary modules can be used in con-
junction with the core CFI and the CFI–Informant Version or as part of a stand-alone
interview. In addition, the supplementary modules are invaluable tools for education
and research. In psychiatry residency programs, for example, when residents are
taught about cultural identity, the role of the social network in care, or explanatory
models, they could be assigned interviews with a certain number of patients using
the pertinent module(s) as further training in the relevant assessment area (for more
information, see Chapter 5, “Cultural Competence in Psychiatric Education Using
the Cultural Formulation Interview”). In terms of research, the modules are particu-
larly suited for qualitative studies profiling key themes on either particular topics
(e.g., caregiving practices) or specific patient groups. For example, the Coping and
Help Seeking module could be used to study patients with a particular diagnosis or
complaint. These reported diagnoses or complaints might include a range of catego-
ries, biomedical as well as local: “first-episode psychosis,” “demoralization,”
“nervios,” or “hyperactivity.” The special populations modules could help ascertain
key topics in the care of the group(s) in question—immigrants, older adults, and so
on. As these examples suggest, the supplementary modules are a valuable tool for
clinicians, trainees, educators, and researchers.
Types of Supplementary Modules

The three types of supplementary modules are described in the subsections and in
Figure 3–1 and Tables 3–1 and 3–2. All of the supplementary modules are included
in Appendix C. (These modules are also available online at www.psychiatry.org/
practice/dsm/dsm5/online-assessment-measures).
Overview
TABLE 3–1. Core Cultural Formulation Interview (CFI) expansion modules
Module Module subdomains Items in module Related core CFI questions
Explanatory Model General understanding of the problem 14 1–5

Illness prototypes
Causal explanations
Course of illness
Help seeking and treatment expectations
Level of Functioning Each question assesses an area of functioning (e.g., work) 8 3
Social Network Composition of social network 15 5, 6, 12, 15
Social network understanding of problem
Social network response to problem
Social network as a stress/buffer
Social network in treatment
Psychosocial Stressors Most questions assess a particular aspect of stressors 5 7, 9, 10, 12
(e.g., how the patient copes, how the stressor can be
changed)
Spirituality, Religion, and Moral Spiritual, religious, and moral identity 16 6–12, 14, 15
Traditions Role of spirituality, religion, and moral traditions
Relationship of this subdomain to the problem
Potential stresses or conflicts related to spirituality, reli-
gion, and moral traditions
49
50
TABLE 3–1. Core Cultural Formulation Interview (CFI) expansion modules (continued)
Cultural Identity National, ethnic, and racial background 34 6–10

Language
Migration
Spirituality, religion, and moral traditions
Gender identity

Sexual orientation identity
Coping and Help Seeking Self-coping 13 6, 11, 12, 14, 15
Social network
Help and treatment seeking beyond social network
Current treatment episode
Patient-Clinician Relationship Questions for the patient 12 16
Question for the clinician after the interview
Overview
TABLE 3–2. Special populations modules
School-Age Children and Adolescents Feeling of age appropriateness in different settings 20 8–10
Age-related stressors and supports
Age-related expectations
Transition to adulthood/maturity
Addendum for parents’ interview
Older Adults Conceptions of aging and cultural identity 17 5, 6–10, 12, 13, 15, 16
Conceptions of aging in relationship to illness attribu-
tions and coping
Influence of comorbid medical problems and treat-
ments on illness
Quality and nature of social supports and caregiving
Additional age-related transitions
Positive and negative attitudes toward aging and
clinician-patient relationship
Immigrants and Refugees Background information 18 7–10, 13
Premigration difficulties
Migration-related losses and challenges
Ongoing relationship with country of origin
Resettlement and new life
Relationship with problem
Future expectations
Note. CFI=Cultural Formulation Interview.
51
Core CFI Expansion Modules

The core CFI expansion modules help the clinician examine eight key domains of the
core CFI in more depth. Table 3–1 lists the eight expansion modules, as well as the
subdomains assessed, the total number of items in each supplementary module, and
the core CFI questions that are related to each module. The core CFI expansion mod-
ules assess aspects of the person and the clinical encounter, such as the patient’s social
support system, the patient’s cultural identity, and the clinician-patient relationship,
with a particular focus on the problem that brought him or her to care. Often the mod-
ules overlap, assessing closely related domains. For example, the person’s experience
of spirituality (module 5, Spirituality, Religion, and Moral Traditions) may affect his
or her understanding of the problem (module 1, Explanatory Model) and what help
to seek for it (module 7, Coping and Help Seeking). Most modules expand beyond the
focus on the problem presented, aiming for a broader contextualization of the clinical
situation. As the 12 subchapters illustrate, the domains of the core CFI (e.g., explana-
tory model, self-coping, identity) further explored in the core CFI expansion modules
are profoundly influenced by cultural factors.
Special Populations Modules

Three modules help elicit information from specific types of patient populations.
Two are age-specific modules (module 9, School-Age Children and Adolescents, and
module 10, Older Adults) and one focuses on immigrants and refugees (module 11).
Table 3–2 describes the special populations modules and the subdomains assessed
in each. These modules provide key information about these groups that affects
care. For example, with respect to the age-specific modules, there is considerable
cultural variation in how age-related transitions and challenges are experienced and
negotiated at either end of the age spectrum. Also, with respect to the Immigrants
and Refugees module, the person’s background as an immigrant or refugee affects
many domains, such as identity (e.g., language-based identity) and specific stressors
(e.g., those related to traumatic events and acculturation).
Informant Perspectives Modules

The CFI–Informant Version asks all of the questions in the core CFI but of someone
other than the patient. In this sense, the CFI–Informant Version can be considered
an additional supplementary module of the core CFI. For a discussion of the CFI–
Informant Version, see Chapter 2, “The Core and Informant Cultural Formulation
Interviews in DSM-5.” In addition, supplementary module 12, Caregivers, obtains
information from an informant specifically regarding his or her role as a caregiver.
The core CFI questions that are related to module 12 are 6, 12, and 14. Patients often
have caregivers, who may be family members, friends, or paid workers. A care-
giver’s assistance may involve taking a patient to appointments, arranging medica-
tion, or even more intense care, such as assisting with all daily functions, including
feeding and bathing. The purpose of this module is to examine cultural aspects of
the caregiving experience, including the nature of the caregiving relationship, na-
Overview 53
ture and impact of caregiving activities, and expectations of clinical care. For exam-
ple, how caregivers interpret and respond to mental health problems and the
treatment system, approach their day-to-day caregiving activities, and experience
burden and gratification within the context of the caregiving role will be shaped by
their own cultural orientations as well as other aspects of their identity (Flores et al.
2009; Hinton et al. 2008).
Structure of the Supplementary Modules

All of the supplementary modules share a similar format. They begin by indicating
any questions from the core CFI that are repeated in the module. Instructions for ad-
ministering the module are then provided, followed by an introduction that the clini-
cian orally presents to the patient to frame the module questions. Most modules are
organized in terms of specific subdomains, and each subdomain is assessed by sev-
eral questions. For example, in the Cultural Identity module, the subdomains include
language ability and migration history, assessed by six and nine questions, respec-
tively.
Like the core CFI, the supplementary modules are problem focused in most cases,
in the sense that they try to elicit how the module topic relates to the clinical problem
presented by the patient. Some, like the Cultural Identity module, focus more on as-
pects of the patient’s identity than on a problem per se, although the module still in-
cludes questions about how cultural identity affects the problem. Other modules,
such as the Explanatory Model and the Coping and Help Seeking modules, are fo-
cused exclusively on the presented problem.
In some cases, questions central to one module are also assessed in another be-
cause those questions relate to both modules. For example, the Explanatory Model
module includes an assessment of coping and help seeking because this line of ques-
tioning allows the interviewer to learn more about the person’s explanatory model
through the types of care and assistance sought for the problem.
Conclusion
A subchapter is devoted to each supplementary module. Figure 3–1 and Tables 3–1
and 3–2 help in navigating the succeeding chapters by clarifying how a given supple-
mentary module relates to the other modules and the core CFI. We describe the mod-
ules in more detail in these chapters and provide case examples to illustrate how
these tools can help contextualize a patient’s presentation in terms of his or her ex-
planatory model of illness, level of functioning, social support, or history of coping
with and help seeking for that complaint. Figure 3–1 in particular shows the analytic
lenses the clinician can bring to bear to evaluate a patient. This might be considered
a form of multiaxial analysis, in which the clinician remains acutely aware of poten-
tial analytic dimensions that should always be kept in mind as possible “tools,” just
as a clinician may have in mind certain areas of questioning during the initial evalu-
ation of a patient. These various means of contextualization can be employed not only
during initial assessment but throughout treatment.
KEY CLINICAL POINTS

• The supplementary modules and the Cultural Formulation Interview–Informant
Version help the clinician avoid errors of decontextualization that result from ne-
glecting the patient’s life situation, sense of belonging to one or more social
groups, and understanding of the “problem” and how to obtain help for it, as well
as the views on these issues held by the patient’s close associates.
• Various types of supplementary modules can expand on the basic assessment ob-
tained with the core Cultural Formulation Interview (CFI). Core CFI expansion
modules further evaluate an area already in the core CFI, special populations mod-
ules provide key information about particular groups (e.g., refugees), and the infor-
mant perspectives modules assess the patient’s problem as perceived by another
person in the patient’s social network (e.g., a caregiver).
Questions
1. What are some of the domains that are ignored as part of a decontextualization
error?
2. What are the types of supplementary modules?
3. What are examples of CFI expansion modules?
4. What are examples of informant perspectives modules?
5. What are examples special populations modules?
References
Eisenberg L: Disease and illness: distinctions between professional and popular ideas of sick-
Flores YG, Hinton L, Barker JC, et al: Beyond familism: a case study of the ethics of care of a
Latina caregiver of an elderly parent with dementia. Health Care Women Int 30(12):1055–
1072, 2009 19894151
Guarnaccia PJ, Lewis-Fernández R, Marano MR: Toward a Puerto Rican popular nosology:
nervios and ataque de nervios. Cult Med Psychiatry 27(3):339–366, 2003 14510098
Hinton DE, Good BJ: Culture and PTSD: Trauma in Historical and Global Perspective. Phila-
delphia, University of Pennsylvania Press, in press
Hinton DE, Lewis-Fernández R: Idioms of distress among trauma survivors: subtypes and clin-
ical utility. Cult Med Psychiatry 34(2):209–218, 2010 20407812
Hinton DE, Lewis-Fernández R: The cross-cultural validity of posttraumatic stress disorder:
implications for DSM-5. Depress Anxiety 28(9):783–801, 2011 21910185
Hinton DE, Nickerson A, Bryant RA: Worry, worry attacks, and PTSD among Cambodian ref-
ugees: a path analysis investigation. Soc Sci Med 72(11):1817–1825, 2011 21663803
Overview 55
Hinton L, Tran JN, Tran C, et al: Religious and spiritual dimensions of the Vietnamese dementia
caregiving experience. Hallym Int J Aging HIJA 10(2):139–160, 2008 20930949
Kleinman A: Social Origins of Distress and Disease: Depression, Neurasthenia, and Pain in
Modern China. New Haven, CT, Yale University Press, 1986
Miller KE, Rasmussen A: War exposure, daily stressors, and mental health in conflict and post-
conflict settings: bridging the divide between trauma-focused and psychosocial frame-
works. Soc Sci Med 70(1):7–16, 2010 19854552
Weiner SJ, Schwartz A, Weaver F, et al: Contextual errors and failures in individualizing patient
care: a multicenter study. Ann Intern Med 153(2):69–75, 2010 20643988
Suggested Readings
Eisenberg L: Disease and illness: distinctions between professional and popular ideas of sick-
Explanatory Model
The concept of the illness explanatory models was introduced in psychiatry

by Arthur Kleinman (1980). The concept is based on ethnographic research that indi-
cated the clinical value of eliciting patients’ models or explanations of their symptoms
and afflictions. Research in medical sociology and psychology on illness behavior and
commonsense illness representations supported the importance of such models as
determinants of symptom experiencing and symptom-related coping and help seek-
ing (Leventhal et al. 1980; Mechanic 1972).
Kleinman (1980) proposed eight simple questions that clinicians could ask to get
a sense of patients’ understanding of their problems, expectations, and concerns (see
also Kleinman et al. 1978). This approach to explanatory models of illness has been
highly influential in medical training, as well as in both clinical practice and research
in cultural psychiatry (Weiss and Somma 2007). An illness explanatory model typi-
cally includes a patient’s ideas about the causes of the problem; about its psycholog-
ical, somatic, social, and/or spiritual effects over time; and about what would be the
most appropriate and effective treatment. Patients’ explanatory models of their
symptoms and complaints may differ markedly from those of the treating clinician
(Helman 1985), and this difference can profoundly influence help seeking, treatment
adherence, clinical course, and outcome.
The models that patients use to make sense of their experience are not only personal
but are also influenced by and shared with those around them. Each patient lives in one
or more particular “cultural contexts,” which shape the problem he or she presents and
the experience of illness and its meaning—that is, how the patient interprets the prob-
lem’s significance and what the patient perceives to be the cause of the clinical problem.
These conceptualizations shape the particular concerns and ideas about what to do (Kir-
mayer and Bhugra 2009; Kleinman 1988). For the purposes of this book, we consider cul-
ture broadly to include ethnic or national group, religious group, gender-based identity,
and work group (e.g., the “culture” of the U.S. veterans who were deployed to Iraq).
56
Supplementary Module 1: Explanatory Model 57
Explanatory models may vary with the type of complaint presented, and patients
may have multiple concerns that they link to a single explanatory model or multiple
explanatory models for the same complaint. The problem that a patient presents may
include a relationship issue, a mood disturbance (e.g., anxiety or hopelessness), and
somatic complaints. The complaints presented may also be a cultural concept of dis-
tress, such as an idiom of distress; for example, English speakers in the United States
may refer to “being stressed,” which invokes a popular model of symptom produc-
tion (Young 1980). DSM-5 (American Psychiatric Association 2013) describes various
cultural concepts of distress. For example, people from many cultural groups may
present with symptoms that they describe in terms of the idiom of “thinking too
much”: Latino patients may refer to this as pensar mucho, Zimbabwean individuals
may speak of kufungisisa, Mandarin-speaking Chinese patients may mention xiang tai
duo, and Cambodian refugees may refer to kut caraeun (Hinton et al., in press; Patel et
al. 1995; Yang et al. 2010; Yarris 2011). Or in South Asia, patients may explain a wide
range of symptoms as due to their loss of dhat, a bodily humor identified with semen
and associated with vital energy for which patients may expect tonics or other restor-
ative treatment (Sumathipala et al. 2004).
In this subchapter, we review several approaches to assessing explanatory models.
We then detail the approach adopted in the Cultural Formulation Interview (CFI) and
provide examples of how the information so gained can be used clinically. We also sum-
marize how administering the CFI helps to accomplish five key clinical tasks.
Measures to Assess Explanatory Models

The DSM-IV (American Psychiatric Association 1994) Outline for Cultural Formula-
tion suggested examining certain aspects of explanatory models of illness (e.g., per-
ceived causes) but did not specifically show how to elicit all of its dimensions. For
research studies, various instruments have been developed to more systematically as-
sess the construct. The Explanatory Model Interview Catalogue (EMIC) is an ap-
proach based on use of a semistructured interview that can be adapted to different
contexts (Weiss 1997). EMIC interviews have a structure that enables comparison of
the distribution of categories of illness-related experience, meaning, and behavior—
that is, a cultural epidemiology (Weiss 2001)—elaborated and integrated with com-
plementary narratives. Some other approaches, such as the Short Explanatory Model
Interview (Lloyd et al. 1998), rely primarily on patients’ narrative accounts of their
problems. The McGill Illness Narrative Interview (MINI) is a semistructured protocol
to identify explanatory models as one component of a broader exploration of illness
experience (Groleau et al. 2006). The MINI is based on evidence that people use mul-
tiple types of models in thinking about illness. The interview aims to elicit three types
of illness models or representations: chain complexes (implicit models structured by
contiguity or metonymy), prototypes (models structured by analogies to salient im-
ages or exemplars), and causal explanations. Although usually woven together in a
narrative, these different types of model or representation can be reliably identified
in research data coding (Stern and Kirmayer 2004). Self-report checklists have also
been used to study explanatory models (Bhui et al. 2006). Finally, there have been ini-
tial efforts to examine implicit models through indirect assessments because of con-
cerns about distortions influenced by social desirability and other limitations in
patients’ responses to direct questions (Ghane et al. 2012).
Overview of the Supplementary Module

The Explanatory Model supplementary module can be found in Appendix C of this
volume. All questions of the Explanatory Model module refer to the problem presented
by the patient. The 14 questions of the module are divided into five sections, as de-
scribed in the following subsections. In the description of the five sections, we also dis-
cuss the clinical importance of the questions, but we address clinical utility in more
detail in the section “Why Assessing the Patient's Explanatory Models Is Important.”
General Understanding of the Problem

Questions 1 and 2 are general probes to elicit the patient’s understanding of the prob-
lem, setting the stage for the questions that follow to elaborate aspects of the explan-
atory model. For example, the first question asks, “Can you tell me more about how
you understand your [PROBLEM]?”
Illness Prototypes
Questions 3–5 identify illness prototypes—that is, the patient’s ideas about the condition
based on knowledge of others with the condition, media attention to the problem, or the
patient’s own past experience with a similar situation (Kirmayer and Bhugra 2009). Pa-
tients are asked about the source(s) of information that shaped their understanding of the
disorder. For example, one question asks, “Do you know anyone else, or heard of anyone
else, with this [PROBLEM]? If so, please describe that person’s [PROBLEM] and how it
affected that person. Do you think this will happen to you?” This multipart question aims
to evoke a patient’s expectations about the problem presented and what might happen
subsequently. For example, a patient may have a relative who was hospitalized for psy-
chiatric illness, and the patient may assume that his or her own condition “runs in the
family” and requires the same treatment. Similarly, in many parts of the world, serious
mental disorders are associated with long-term institutionalization, and patients labeled
with any psychiatric diagnosis may fear this outcome. A frequent example in the United
States involves the impact that media coverage of attention-deficit/hyperactivity disor-
der (ADHD) has on many adolescents and their parents. Increased cultural awareness of
this illness prototype is leading youth to present for treatment from mental health profes-
sionals for many kinds of school and behavior difficulties that they, their parents, or
school officials mistakenly attribute to ADHD (Batstra et al. 2014).
Video 2 demonstrates the identification of a patient’s illness prototype.
Video Illustration 2: What does that have to do with my lungs? (4:26)
In this video, a consultation-liaison psychiatrist illustrates how to use some

questions from the Explanatory Model to supplement a core CFI assessment
with an African American woman who is hospitalized in a general hospital

ward. The consultation aims to elucidate possible psychiatric aspects of her
lung complaints and, in particular, her reasons for refusing indicated tests. The
clinician appropriately frames the interview, stating that his questions aim to
advance care and that there are no right or wrong answers. When asked about
her understanding of her lung problems and the connection to smoking, the
patient states that her husband had lung complaints, entered the hospital, and
died; she asserts that the doctors killed him by subjecting him to a lot of unnec-
essary tests. She says she just wants to get something to help her breathing so
she can go home and expresses being upset at having to see a psychiatrist. She
also does not want any testing. Since her husband had the same tests, she is
afraid the doctors will kill her, like her husband, through the tests.
The patient thus demonstrates having an illness prototype—namely, a certain
understanding of her complaint (“I can’t breathe”) and an expected treatment
course in the hospital based on the experience of someone she knew (her hus-
band) with the same complaint. The interviewer tries to explore whether there
are other sources of the illness prototype by questioning her further about her
breathing problems, specifically inquiring about the Internet or television pro-
grams. The patient’s answers confirm that the main source of her illness proto-
type is her husband’s experience: “He came into the hospital, he had a problem
breathing, he came into the hospital. They killed him. And they took his lungs,
and they took his heart, and they took everything else.”
The clinician’s use of the Explanatory Module provides useful information.
The interview reveals that the patient has catastrophic cognitions about her ill-
ness course that originate from her understanding of her husband’s hospital
experience. She believes the tests given at the hospital, possibly with the goal
of harvesting her organs, will kill her rather than advance her care.
As the interviewer completes the Explanatory Model module, he can explore
the patient’s core complaint further. What does she think caused her difficulty
breathing? What does she think her illness course will be? What treatment
would be best? This information can also help answer another clinical question
raised by the patient’s fears of medical experimentation: Is she psychotic, or is
her fear the result of nonpsychotic-level mistrust of hospital care possibly com-
bined with low health literacy and insufficient explanation by her treatment
team? More information about her presented complaint can help answer these
questions and guide the clinician’s explanation for the planned assessments
and their treatment implications. This is called explanatory model bridging: the ne-
gotiation of the two explanatory models present in the clinical encounter—that
of the patient and that of the clinician. Through this bridging process, the pa-
tient’s illness prototype is further elucidated, helping to resolve a clinical im-
passe. For example, more information on the patient’s explanatory model could
help explain how the patient thinks the tests killed her husband. This may help
to address her catastrophic cognitions about planned assessments and treat-
ments, possibly optimizing her treatment engagement and positive expectancy.
Causal Explanations
Questions 6–9 elaborate on perceived causes of a problem to determine how a patient
understands its source, reasons, and consequences. For example, “Can you tell me
what you think caused your [PROBLEM]?” and “How do you think your [PROB-
LEM] affects your body? Your mind? Your spiritual well-being?” These questions get
at the patient’s ideas of how the problem “works”—that is, its causal mechanisms, in-
cluding pathophysiology, psychology, and social, spiritual, or other processes. Fre-
quently, these questions also elicit concerns related to self-stigmatization and
anticipated social stigmatization associated with the problem (i.e., ideas about how
the disorder is a shameful condition and will provoke negative social responses). For
example, patients may consider their anxiety to be the result of committing moral or
religious sins or transgressions. Very commonly, a patient may describe the cause as
“stress” but have specific culturally influenced ideas about the causes and negative
consequences of the condition. Such information provides the clinician an opportu-
nity to address stigma (e.g., by describing the condition as a common condition ame-
nable to appropriate treatment), to modify catastrophic cognitions (e.g., by explaining
that the symptoms are caused by anxiety rather than some intrinsic fault or inexora-
ble mechanism), to optimize adherence and positive expectations (e.g., by framing
the treatment as addressing the conditions of concern and potential social responses),
and to build rapport (e.g., by enhancing empathy and helping to make a patient feel
understood). Other questions in the section on causal explanations clarify whether
someone’s explanatory model has changed over time, whether multiple and even
conflicting explanatory models coexist, and whether others in the patient’s social net-
work have alternative explanatory models. The clinician may find that certain ex-
planatory models of others in the family or social network have strongly influenced
a patient’s experience and illness behavior. The clinician may need to acknowledge or
respond to these explanations if they cause concern, are harmful or stigmatizing, or
jeopardize effective treatment.
Videos 3 and 4 illustrate the use of the Explanatory Model supplementary module.
Video Illustration 3: They get outta whack sometimes (2:19)
Video Illustration 4: If it’s not one thing, it’s another (3:46)
In videos 3 and 4, which are two parts of the same session, a mental health cli-
nician illustrates the use of the Explanatory Model supplementary module
through an interview with a 30-year-old Jewish woman referred for recurrent
depression and past suicidal ideation. Video 3, titled They get outta whack some-
times, shows the patient’s answers to the first three questions of the supple-
mentary module. Video 4, If it’s not one thing, it’s another, contains the patient’s
answers to questions 6–8 of the module.
The interviews in videos 3 and 4 occur after the core CFI has taken place. The
therapist appropriately couches the questions in the patient’s own words for
describing her depressive illness, which she labels “feeling down” and being
“moody.” The patient’s general understanding of the illness is that it results

from “chemicals in the brain... [that] get outta whack,” so that “some people
are just wired to not be happy all the time.” Initially, she says that her symp-
toms have little relationship with actual events, but as the interview pro-
gresses—particularly as she describes her family’s ideas about what causes her
illness—she discusses stressors associated with her condition, such as feeling
frustrated with her job and with her lack of a romantic relationship. The second
question in the module —What did you know about feeling down before it af-
fected you?—elicits some information about her illness prototype: an aunt who
was known to have “down time” and who suffered the “weeps.” Question 3
continues to explore past influences on her illness explanations. Here she adds
that her mother used to label her as being “too moody” and took her for psy-
chiatric intervention in adolescence. The patient saw a “shrink” for 10 years
and thought it very helpful. However, the therapist became ill, leading to ces-
sation of treatment. Questions 6 and 7 on causes go on to elicit information
about how the patient tries to cope with her symptoms and her frustration at
the limited effectiveness of the coping mechanisms. She also talks about her
past exacerbations, including her suicidal ideation in college, her difficulties
engaging the support of several members of her family, and the stresses of her
work situation.
The interviewer moves in order through the domains of the Explanatory
Model supplementary module, indicating the value of a systematic approach
to the topic. By continuing to pursue the module, he can now explore several
aspects of her Explanatory Model in more depth. The initial information on her
aunt could be followed up with questions about that relative’s illness course
and what treatments she received. This could lead naturally to the questions in
the module on the course of the patient’s own illness. What does she expect
from this course? How serious is her condition? What is its prognosis? Does the
fact that the problem involves “brain chemicals” mean that it is permanent, or
is it amenable to change? How does her condition compare to her aunt’s? Did
her aunt actually receive treatment? What was the outcome? Subsequent sec-
tions of the module can also explore her help seeking and treatment expecta-
tions, building on the information already provided about the patient’s
previous successful experience with her high school therapist. This informa-
tion can help the clinician clarify what the patient expects from her current
treatment and what potential areas of shared understanding and intervention
can be expected going forward in care.
Course of Illness
Questions 10–12 ask about how patients understand what happens to people with con-
ditions like their own and what to expect. These expectations may be based on causal
explanations, self-image, past experience, or salient prototypes. For example, one ques-
tion asks, “What usually happens to people who have this [PROBLEM]? In your own
case, what do you think is likely to happen?” Some patients have more positive views
of potential outcome than do their clinicians, especially those patients with milder con-
ditions or those who do not seek help from mental health practitioners. In primary care,
for example, patients may believe that the symptoms that the clinician has diagnosed
as part of major depression are simply “problems of living,” which will improve over
time if only the precipitating difficulties improve. Other patients, however, may antici-
pate dire consequences, such as the idea that their “sadness” will never end and will
ultimately progress to a vegetative-like state. Both situations indicate potential for a
mismatch between the expectations of patients and clinicians, which if unaddressed
can undermine a collaborative approach to care. Eliciting the views of others in the pa-
tient’s social network helps to determine if such ideas need to be addressed. For exam-
ple, if an influential person in the patient’s social network, such as a parent, has an
unduly negative or positive view of the expected course, this should be addressed to
ensure realistic expectations and appropriate support.
Help Seeking and Treatment Expectations

Questions 13 and 14 explore what patients and others close to them regard as the
most appropriate treatment for the problem. For example, one question asks, “What
do you think is the best way to deal with this kind of problem?” The patient’s expla-
nation may provide a rationale for specific types of coping or intervention. This in-
formation may help a clinician to choose what treatment approaches to suggest and
to begin a process of negotiation and shared decision making. For example, the clini-
cian may encourage the patient to combine psychotherapy with other ways of deal-
ing with the problem, such as prayer, other forms of supportive spiritual practice,
exercise, or other activities. Accepting, or at least becoming aware of, the patient’s
preferred modes of coping and healing may result in better rapport and effective-
ness. The clinician may also discover that the patient misunderstands the treatment
available at the clinic, and this provides a chance to clarify. The questions in the help-
seeking and treatment expectations section also give the clinician an opportunity to
link the suggested treatment with the patient’s presented complaint.
Why Assessing Patients’ Explanatory Models

Is Important
Exploring the patient’s explanatory model can help accomplish five key clinical tasks,
which were suggested by some of the examples provided in the preceding discussion
of the content of the CFI (Hinton and Lewis-Fernández 2010). These tasks are de-
scribed in the following sections.
Maximizing Treatment Engagement and Adherence

The clinician promotes engagement and adherence by describing the recommended
treatment in a way that makes clear to a patient how treatment will address the prob-
lem presented. This requires linking the treatment to the patient’s explanatory model
in some way; this might be called explanatory model bridging. Simply taking the time
to learn what the patient thinks causes the presented problem conveys a sense that
the clinician understands and cares about the patient’s concerns, which gives greater
credence to subsequent treatment proposals. Eliciting explanatory models of prob-
lems that arise during care, such as medication side effects, may also contribute to
clinical effectiveness. For example, a mild medication-induced tremor may be inter-
preted by a Caribbean Latina patient as a worrisome sign of impending “alteration of
the nerves,” possibly resulting in nervous system collapse and loss of motor function
(Lewis-Fernández 2014).
Increasing Positive Expectancy

A large literature indicates that treatment effectiveness is increased when the patient
has positive expectancy. This effect is found for both psychological interventions and
medication treatment (Rutherford and Roose 2013; Tsai et al. 2014). Positive expec-
tancy effects account for a substantial amount of variance in studies of psychological
and psychopharmacological treatments. To increase positive expectancy, the treat-
ment should be framed in ways that address a patient’s key concerns to make the
value of treatment more credible. Understanding the patient’s explanatory model
makes this possible. For example, patients from several Asian groups may attribute
many psychological disorders and problems—and their associated somatic symp-
toms—to physical, mental, and/or spiritual weakness. In China, for instance, local
models of neurasthenia may relate complaints of weakness to concepts of energy loss
or imbalance (Kleinman 1986). Thus, in treating a person of Chinese origin with so-
matic symptoms of weakness, nervousness, or irritability, a clinician may use the CFI
to clarify how symptoms are related to the person’s explanatory model. Having as-
certained the patient’s explanation of “weakness” through the CFI, the clinician can
then use similar terms to explain how the treatment works, for instance, by noting
that antidepressants may increase a sense of energy by improving sleep and appetite
or through direct effects on the nervous system. Alternatively, if the CFI shows that a
patient regards bodily and psychological distress as a result of inner heat—as is seen,
for example, among certain African populations (Thompson 2011)—the medication
could be described as “cooling.” In general, the aim is to frame the medicine and ex-
plain its action in ways that are both consistent with its known effects and intelligible
to patients in terms of their personal and cultural explanatory models.
Building Empathy and Therapeutic Alliance

Explicit attention to the patients’ own understanding of their problems is an indica-
tion of a clinician’s empathy, which strengthens the clinical alliance. Explanatory
models may link patients’ concerns to past or current ideas about causes and future
consequences, which have their own personal, social, and moral implications. A full
and practical appreciation of patients’ concerns therefore benefits from tracing the
paths of causal influence, identifying salient prototypes, and exploring their personal
and cultural meanings. This enhanced understanding can improve the empathic
bond and thus increase the treatment alliance, adherence, and the effectiveness of in-
terventions (Kirmayer 2013).
Addressing Catastrophic Cognitions

Explanatory models of a problem influence a person’s cognitive-emotional response.
In particular, attributions of symptoms to potentially serious or life-threatening
causes may lead to excessive worry and give rise to catastrophic cognitions. For ex-
ample, some Latino patients may be concerned that worry will permanently impair
memory. Understanding such concerns can help a clinician address misunderstand-
ings or misinterpretations of their problems that contribute to patients’ distress. So-
cial contexts give rise to explanations for health problems that circulate in society and
influence ways of thinking and explaining problems. For example, a veteran of the
war in Iraq may consider poor concentration resulting from anxiety to be an indicator
of traumatic brain injury (Boehnlein and Hinton, in press). If the patient is troubled
by this core concern, then explaining the link between poor concentration and anxiety
may be reassuring and motivate adherence to treatment. Similarly, explanations of so-
matic complaints may refer to local cultural physiology (ethnophysiology), including
links between social stressors and physiology (sociosomatics) (Groleau and Kirmayer
2004; Hinton et al. 2011; Kirmayer et al. 2004). For instance, among Cambodian refu-
gees, dizziness is often attributed to an abnormal flow of khyâl in the body, called a
khyâl attack, which may be caused by worry, among other causes (a sociosomatic ex-
planation), and this interpretation often leads to catastrophic cognitions about so-
matic sensations, resulting in frequent panic attacks (Hinton et al. 2010). Modifying
those catastrophic cognitions will have great therapeutic effect.
Addressing Stigmatization
Certain groups may consider particular symptoms or types of illness as shameful and
stigmatizing. Veterans, for example, often consider having posttraumatic stress disorder
to be a “weakness,” and they are therefore reluctant to seek services. They may refuse
treatment for fear of being labeled “crazy” and weak (Finley 2011). Similarly, police offi-
cers in the United States may be loath to report psychological difficulties in coping with a
job-related traumatic event, so they might thereby avoid the anticipated stigmatization by
their peer group for a mental health referral. Such stigma may have consequences. Af-
fected persons may be regarded as emotionally unstable, have their weapons removed,
and be assigned to desk duty. For certain Asian groups, mental illness in a family member
may be viewed as a defect shared by or transmitted to others in the family and their off-
spring. In many South Asian communities, this belief may complicate the family duty of
arranging a daughter’s marriage. Understanding the social implications of an explana-
tory model and its associated stigma provides awareness and an opportunity to address
stigma in treatment (Yang et al. 2014), which may, in turn, facilitate negotiation of treat-
ment options, adherence, and better outcomes.
Conclusion
In this subchapter, we have tried to illustrate the clinical value of eliciting explanatory
models of the presented problem as done in the Explanatory Model supplementary
module. We have discussed how the information gleaned from the module—illness
prototypes, causal explanations, expected course of illness, help seeking, and treatment
expectations—can help the clinician accomplish key clinical and therapeutic tasks.
The Explanatory Model module can help the clinician to explore patients’ under-
standing of their problems and to illuminate those problems within the context of the
patients’ social world. The module helps in understanding the way the person makes
sense of his or her situation by using meaning systems shared with his or her family,
friends, and immediate social network, as well as knowledge circulating in mass media.
Many patients have multiple models that address different aspects of their problem,
and many patients experience conflicts between their own explanations for their dis-
tress and the explanations favored by others around them. Attending to explanatory
models, including the personal, social, and cultural sources of explanatory models and
conflicts among competing explanatory models, is one way to avoid the error of decon-
textualization—the mistake of taking the presented problem out of its culturally shaped
social and meaning context (Hinton and Good, in press; Weiner et al. 2010).
As we have tried to illustrate in this subchapter, patients understand their prob-
lems to have certain causes, consequences, and effects and mechanisms of action in
the body, mind, and spiritual realm, and these conceptualizations may contribute to
expectations for specific forms of healing and treatment. Clinicians must assess each
patient’s understanding of his or her presented complaint and related problems in his
or her social and cultural context in order to accomplish key therapeutic tasks. The
Explanatory Model module provides a way to begin this process.
KEY CLINICAL POINTS

• An illness explanatory model typically includes a patient’s ideas about the causes of
the problem; about the problem’s psychological, somatic, social, and/or spiritual effects
over time; and about what would be the most appropriate and efficacious treatment.
• Eliciting the patient’s explanatory model(s) using the core Cultural Formulation In-
terview and the Explanatory Model supplementary module provides various types
of potential clinical utility, such as improving adherence to treatment, building em-
pathic rapport, addressing catastrophic cognitions, and allowing the bridging of the
patient’s and clinician’s explanatory models.
Questions
1. What are explanatory models?
2. What clinical utility is provided by assessing the patient’s explanatory model(s)?
3. How does eliciting the patient's explanatory model increase treatment engage-
ment and adherence?
4. How does eliciting the patient's explanatory model increase positive expec-
tancy?
5. What is explanatory model bridging?

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Level of Functioning
Improving functional outcomes is an important goal of any intervention and

thus a core component of psychiatric assessment. How can a clinician accurately es-
timate what constitutes a “normal” level and type of activity for a patient, while keep-
ing in mind the person’s social and cultural circumstances? The Level of Functioning
supplementary module of the DSM-5 (American Psychiatric Association 2013) Cul-
tural Formulation Interview (CFI) was developed to assist clinicians in taking culture
into account when assessing the patient’s level of functioning. Our goals in this sub-
chapter are to describe the rationale for, contents of, and use of the Level of Function-
ing module in the clinical assessment and care of patients from diverse cultural
backgrounds.
Rationale for the Supplementary Module

Culture and society define the value of every aspect of functioning—including per-
sonal care, housework activities, occupation, and income—as well as the meanings of
terms that are commonly used to assess level of functioning. Culture and context in-
fluence patients’ narratives as well as mental health workers’ evaluation of symptoms
and disability. In some cultures, successful functioning may be considered to be
largely limited to paid employment activities that result in economic productivity
and financial stability, whereas in other cultures, self-satisfaction rather than type of
work may be perceived to be more important. Technologically developed cultures
may value cognitive abilities above paid manual work.
Cultural background affects the expression of psychological distress, an impor-
tant concept in DSM-5. With increasing migration of people all over the world, health
care workers must be aware of cultural issues in the expression of symptoms and id-
ioms of distress. For patients unfamiliar with a wide range of emotional or psycho-
logical terms, clinician awareness of how changes in level of function are related to
68
Supplementary Module 2: Level of Functioning 69
cultural norms can be helpful for diagnostic evaluation. How a person functions in
society in relation to work, interpersonal matters, coping, and self-esteem is one of the
most important issues in assessing recovery.
Internationally used health assessment scales with appropriate cross-cultural ad-
aptations and satisfactory psychometric properties that can accurately measure levels
of cognition, mood, activities of daily living (ADLs), health-related quality of life, and
loneliness may yet be insufficient for this purpose, and psychometric properties of
many translated health assessment scales have not been fully tested (Uysal-Bozkir et
al. 2013). Cross-cultural adaptation of scales of functioning must account for culture
and belief systems—for instance, a level of functioning scale that is not gender sensi-
tive may misclassify males who perform only household chores or women who are
not permitted outdoor activities in their culture as inactive or impaired. In many
Western societies, older citizens are expected to care for themselves independently,
whereas in India, laws mandate that children take care of their aged parents (Mainte-
nance and Welfare of Parents and Senior Citizens Act 2007). Thus, older adults would
perforce appear to be more functional in Western cultures than in India, where they
are “being cared for” and possibly mislabeled as impaired. Patients seeking health
care in India are usually accompanied by the family caregiver, who assesses and re-
ports their functioning. The expectations of the family may then determine reports on
the person’s level of functioning at any stage of life.
Disability may be a more quantifiable measure of functioning from a mental health
perspective. The World Health Organization (2002) views disability as a contextual
variable that is dynamic over time in relation to circumstances and defines it as the “gap
between capacity and performance” and outcome (p. 13). The degree of disability is
based on the interaction between the individual and his or her personal, institutional,
and social environments. The assessment of disability should also be supplemented by
information on the person’s ability to engage in out rehabilitation plans.

The Level of Functioning supplementary module (provided in Appendix C in this
handbook) aims to address all areas of daily living likely to be affected by psycholog-
ical distress. The module investigates several aspects of functioning through open-
ended questions about each aspect, enabling the interviewer to focus on specific areas
of concern as well as enabling further research in this area. Question 1 deals with
ADLs; it touches on activities as well as responsibilities in a person’s daily life. The
focus on daily duties can be very specific to culture and gender, and therefore this
question affords a good evaluation of the degree of deterioration. Changes in culture-
and gender-patterned responsibilities, such as cooking, shopping, working outside
the home, or independent living, provide good indicators not only of the person’s
participation in the usual cultural norms of his or her community but also of the pa-
tient’s level of dysfunction. Although deficits in ADLs have been investigated exten-
sively in dementia, ADLs are adversely affected in almost all mental disorders.
Question 3, on how the problem affects the patient’s ability to work, starts to ad-
dress the possibility of unemployment associated with serious mental illness. Al-
though problems with employment may be the outcome of cognitive impairment and
psychopathology, they are also strongly influenced by societal and economic pres-
sures, availability of jobs, stigma, discrimination, and psychological and social barri-
ers to working. The question about work also enables the clinician to broach the topic
of other types of occupational activities, such as full-time or part-time study. Expec-
tations regarding engagement in school are strongly influenced by cultural and con-
textual factors around the world; these factors include age, gender, socioeconomic
status, and religion. Low social and family expectations about engaging in study and
employment are strong barriers to active engagement in these activities, especially in
the context of psychiatric illness. Question 4, which asks about the person’s financial
situation, is important because mental illness and poverty are intertwined, resulting
in lower educational and socioeconomic outcomes for patients’ families as well
(Wolfe et al. 2014). Although loss of income may lead to mental distress or disorder,
mental illness itself may be linked to subsequent poverty through many intervening
factors (Chatterjee 2009; Draine 2013).
Social and community functioning is a multidimensional construct implying
overall performance across everyday domains (Green 1996). The Level of Function-
ing module asks about the person’s interactions with family and other members of his
or her social network (question 2) and about how troubling disturbances in the pa-
tient’s functioning are to them (question 8). Social functioning, social cognition, and
social interaction, although most affected during episodes of active illness, often re-
main impaired during remissions, especially of serious mental illnesses. These con-
cerns are addressed by question 5. Reinduction into social roles is an important aspect
of recovery from severe mental illnesses (De Silva et al. 2013). Inability to experience
pleasure in everyday activities is an important symptom of illness (question 6). Ad-
ditionally, the module inquires about the aspect of lack of functioning that troubles
the person to the greatest extent (question 7) and about the patient’s ability to cope
with the difficulties that arise day to day. Questions about community participation
(question 5) and the family's concerns (question 8) help focus rehabilitation efforts on
person-centered yet culturally grounded targets.
Video 5 demonstrates an assessment of the patient’s level of functioning.
Video Illustration 5: DWI (3:46)
This video illustrates how to use the CFI supplementary module on level of
functioning to assess how a patient’s drinking problem affects his work, earn-
ings, life goals, and relationships. Substance use problems are universal and
are often characterized by denial. Yet, in this video, by first focusing on the re-
sult of his drinking (“driving tickets”), the interviewer is able to elicit a good
description of his drinking habits as well. The questions on level of functioning
serve to define the presented problem and clarify the diagnosis.
The video begins after the module has been introduced by the clinician and the
first question has already been asked. The interview illustrates how useful it is
for the patient to describe how his drinking problem has affected not only his
ability to earn a living but also his closest relationships. We learn that he drinks
alone, he has no money, he has lost friends, and his parents have been hurt by
his drinking. He no longer thinks of marrying because he has neither the time
nor the money. Voicing these concerns can help the patient realize the extent of
his problem and set goals for his recovery. Over time, following up on the an-
swers to these questions could also help the clinician evaluate the effects of
treatment.
On a deeper level, the module may help the interviewer and the patient de-
velop an empathic rapport by demonstrating the clinician’s willingness to ex-
plore the patient’s daily concerns and to impart hope to the patient of
achieving his life goals by taking control of his problem—helping his parents,
getting married, and feeling less lonely and isolated. The standard psychiatric
history and mental status examination can leave important areas of patient
concern unexplored if done with a stereotyped, one-size-fits-all approach. By
focusing on the patient’s own assessment of the problem’s impact, the Level of
Functioning module can yield a personalized description of what is troubling
the person the most about his or her situation, facilitating greater insight and
engagement. This is evidenced in the video despite the patient’s somewhat
limited English-language proficiency. The interviewer’s nonjudgmental ap-
proach when asking about the patient’s functioning and relationships in daily
life may also help the patient discuss the effects of his drinking as well as the
possible benefits of change.
Guidelines for Clinical Use of the Module

The first two questions of the core CFI—about how the patient would describe the
problem that triggered seeking care to the clinician and to his or her family—may not
yield sufficient information on how the symptoms impair the patient's normal func-
tioning as culturally perceived by the person and his or her community. Use of the
Level of Functioning module may be considered when more information is required
on the impact of symptoms and the effects of the illness on various day-to-day activ-
ities, while taking into account the individual’s own cultural point of reference.
The module may be particularly useful when the clinician is unfamiliar with the
social and cultural milieu of the patient and when patients are not accustomed to for-
mulating suffering in the vocabulary of the clinician—for example, when the individ-
ual initially presents the impact of his or her suffering in terms of bodily idioms of
distress, changed behavior, or impaired relations, but not in emotional or psycholog-
ical terms. In many cultures, disturbances of mood and affect, as well as anxiety, may
be viewed not as mental problems but instead as social and moral problems (Kir-
mayer 2001) and therefore may be described in terms of decreased activities and im-
paired relations. The Level of Functioning module can help clinicians clarify the level
of impairment so as to formulate culturally sensitive management and treatment in-
terventions.
Because the Level of Functioning module is short, with only eight open-ended
questions, it can easily be combined with other instruments that provide a more item-
ized evaluation of disability, such as the World Health Organization Disability As-
sessment Schedule (WHODAS), version 2.0 (World Health Organization 2010). The
open-ended approach of the Level of Functioning module complements the closed-
ended, more decontextualized approach of instruments such as the WHODAS, po-
tentially leading to a more culturally and contextually sensitive evaluation of level of
functioning. Use of the closed-ended measures alone may not detect important differ-
ences in functioning across diagnostic groupings (Chakraborty et al. 2011). The fol-
lowing cases illustrate the clinical use of the Level of Functioning module.
Case Vignette 1
Psychiatric evaluation by a female psychiatrist of Greek origin did not reveal active
psychotic symptoms in Johan, a 21-year-old unmarried man living with his family on a
small farm in northern Sweden, who was referred for outpatient care after hospitaliza-
tion for first-episode psychosis. Having left school earlier than expected in his social cir-
cle, Johan took various temporary jobs during the summers and did carpentry by
himself at home during the winters. Six months after his initial evaluation, he partici-
pated in an interview with the Level of Functioning module. Johan appreciated the ad-
ditional interview; he interpreted it as a sign of the psychiatrist’s involvement in his
care. During the interview, he revealed that he spent most of his time building a com-
plicated wooden structure in a barn at the farm, guided by an invisible voice telling him
what to do, speaking in Finnish, and calling him by the nickname his grandmother had
given him. He stayed away from the family during these periods, as he felt they would
question and tease him about this voice. Use of the module resulted in an improved
therapeutic alliance with his psychiatrist, and the information obtained led the clinical
team to realize that Johan was still living in a parallel psychotic world and was involved
in daily activities very different from those of his local cultural setting.
Case Vignette 2
Songül, a 48-year-old Turkish immigrant to Sweden, was a mother of five children and
a full-time housekeeping employee who complained of pain of uncertain origin since
the birth of her youngest son. She had been treated with an antidepressant in primary
care but showed poor adherence to medication and no improvement. The CFI, followed
by the Level of Functioning module, was conducted by a male Swedish psychiatric res-
ident with the help of a Turkish interpreter. Songül spoke of her unexplained physical
pain and described how her capacity for doing things at home and at work had de-
clined over the past year, especially in the mornings. On probing, she described other
symptoms, including loss of appetite, loss of pleasure in her children’s attentions and
good academic performance, and growing social withdrawal. She was afraid that her
acquaintances were gossiping about her, and she did not want her family in Turkey to
know about her condition because they would become worried. Combined use of the
CFI and the Level of Functioning module, particularly the questions on daily activities,
helped to clarify that Songül had suffered from depression (which was associated with
the symptoms she called “pain”) for about a year, with substantial functional impair-
ment. The focus on impairment at home and in her job enabled the patient to accept
treatment that was focused on how to improve her daily functioning.
Conclusion
Assessing a patient’s functional capacity and efficiency in conducting self-care, rou-
tine, and work-related activities is a cornerstone of psychiatric assessment. In usual
practice, however, level of functioning receives much less attention than other aspects
of psychopathology, such as symptoms. For patients and caregivers, however, im-
pairment in functioning may be the most obvious manifestation of a psychiatric dis-
order. Clarification of the level of functioning may by itself help identify the
diagnosis, as illustrated in the case vignettes.
Different aspects of functioning are important in diverse situations and indeed at
different points in the life cycle. Although it may not be possible in a busy clinical set-
ting to examine all of them, we expect that the Level of Functioning module will help
focus attention on the most important aspects and help clinicians and patients arrive
at a satisfactory outcome of care.
KEY CLINICAL POINTS

• Culture and society implicitly define the value of every aspect of functioning.
• Level of functioning is a core component of psychiatric assessment, and aware-
ness of how changes in functioning are related to cultural norms can be helpful for
diagnosis.
• The Level of Functioning module can help clarify the patient’s level of impairment
in order to formulate culturally sensitive management and treatment interventions.
Questions
1. How useful is it to evaluate a patient’s level of functioning during routine psy-
chiatric assessments?
2. In cross-cultural situations, what can interfere with the clinician's assessment

of the patient's limitations in daily activities and responsibilities?
3. At which point during the process of psychiatric assessment will the Level of
Functioning module be most useful in daily practice?
4. How important is it in a routine clinical assessment to ask what the patient en-
joys doing?
5. From a cultural perspective, what are the advantages and disadvantages of ex-
ploring the patient's level of functioning with closed versus open questions?
References
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Suggested Readings
and patients’ life context in psychiatric diagnostic practice. Transcult Psychiatry 46:406–
428, 2009
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Health. Geneva, Switzerland, World Health Organization, 2002
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Social Network
Ladson Hinton, M.D.
Social networks often play a pivotal role in the onset, course, and out-
comes of mental health conditions. Social networks are defined as all interpersonal re-
lationships having an impact on a person’s life (Speck and Attneave 1973). For the
purposes of the DSM-5 (American Psychiatric Association 2013) Cultural Formula-
tion Interview (CFI), the term encompasses “family, friends and other social contacts
through work, places of prayer/worship or other activities and affiliations,” as ex-
plained in the introduction to the Social Network supplementary module (see Ap-
pendix C in this handbook). Clinicians who understand the roles of the person’s
social network will be in a much better position to assess and treat persons with men-
tal illness. The structure and qualities of social networks are, in turn, profoundly in-
fluenced by culture. For example, persons with mental illness may suffer as a result
of being shunned or criticized by family or friends who hold culturally shaped and
stigmatized views of mental illness. Alternatively, family or friends may seek to de-
flect stigma and social suffering by drawing on cultural explanations that normalize
the patient’s aberrant behaviors. The core CFI (see Appendix A in this handbook) in-
cludes several questions to elicit the cultural aspects of social networks as they impact
mental health, but in some clinical situations, mental health providers may want to
examine these issues in greater depth. In this subchapter, we examine the importance
of assessing cultural dimensions of social networks as part of a cultural formulation,
describe the Social Network supplementary module, and provide guidance to clini-
cians on when and how to use this module to conduct a more comprehensive cultural
assessment of the impact of social networks on clinical care.
Social Networks, Mental Health, and Culture

There is a large body of work linking social connections to mental health that dates
back to seminal sociological studies from the late 1800s (Durkheim 1951). Inclusion in
a group may promote overall psychological well-being by creating a perception of or-
der and belonging, fostering identity, and increasing self-worth (Smith and Christakis
75
2008; Speck and Attneave 1973). Individuals within social networks often share cul-
tural orientations to health and illness, including perceptions of risk, illness explana-
tory models, constructs of health and well-being, strategies for managing symptoms,
and patterns of care seeking (Kleinman 1987). A person’s decisions about when and
whether to seek care, for example, are often based on consultations with the people
in his or her family and social group regarding the risk, level of perceived pathology,
and seriousness of health-related changes, as well as observations of the actions and
experiences of others in similar circumstances (Christakis and Fowler 2007; Malchodi
et al. 2003; Shalizi and Thomas 2011). Social networks may also promote and/or im-
pede mental health treatment (Hinton et al. 2014). For example, social ties through re-
ligious organizations can offer emotional support and assistance in coping with the
symptoms of mental illness; depending on the orientation of the religious organiza-
tion, faith-based social networks can also discourage help seeking in order to “leave
all in God’s hands” (Williams 2012).
Two models have been offered to explain the connection between social support
and mental health outcomes: the stress-buffering model (Cohen and Wills 1985) and the
main effects model (Lakey and Orehek 2011). The main effects model holds that inclu-
sion and degree of integration in large social networks positively influence mental
health independently of stressors. However, this embeddedness does not influence
coping when the individual is confronted with stressful life events (Cohen and Wills
1985; Cohen et al. 2000; Thoits 2011). The stress-buffering model holds that social sup-
port impacts the pathway from stressful events to mental illness by influencing the
interpretation of the stressful event and the behavioral and neuroendocrine re-
sponses. The perceived availability of interpersonal resources can influence the extent
to which stressful events are perceived as threatening or stressful. Cultural assess-
ment of social networks can help in formulating appropriate treatment recommenda-
tions, because individuals from different groups view relationships and the self in the
context of social norms within their communities (Kim et al. 2008).
In summary, social networks may facilitate or impede access to help, mobilize re-
sources to manage emotional problems, and provide concrete support such as basic
needs (e.g., food), financial aid, counseling, and guidance (Greenblatt et al. 1982; Kog-
stad et al. 2013; Windell and Norman 2013). For example, the economic success of cer-
tain U.S. groups (e.g., Chinese, Cubans, Indians, Iranians, Jews, Lebanese, Mormons,
Nigerians) is influenced by the level of affiliation within their social networks (Chua
and Rubenfeld 2014). In other cases, social networks may trigger or amplify distress
and impede treatment, such as by magnifying the perceived stigma of seeking psy-
chiatric care (Hinton et al. 2014). The Social Network supplementary module aims to
identify how the informal social network influences the problem.

The overall goal of the Social Network module is to assist the clinician in assessing
the influences of the social network on the patient’s mental health problem, with a
particular focus on the role of cultural factors. Prior work has documented both the
stress-amplifying and stress-buffering effects of family, friends, and others on the ex-
Supplementary Module 3: Social Network 77
perience of mental illness (Cohen and Wills 1985). The questions in this module may
help clinicians map the specific roles of the patient’s social network and may help cli-
nicians navigate these sometimes complex interactions to promote more culturally
competent care.
The Social Network module covers five domains. The questions in the first and
second domains are designed to elicit a description of the key individuals in the pa-
tient’s social network and their awareness and understanding of the mental health
problem. The third domain examines the social and behavioral responses of those in
the social network to the patient’s mental health problems. These questions can, for
example, help the clinician assess the role of cultural stigma (question 7: “Do your
family, friends, and other people in your life treat you differently because of your
[PROBLEM]?”) and the role of the social network as a source of advice (question 6:
“What advice have family members and friends given you about your [PROB-
LEM]?”). The fourth set of questions assesses the patient’s perception of the extent to
which those in the social network have made the mental health problem better or
worse. The fifth domain examines the involvement of persons in the social network
in the patient’s mental health care, which may be of value to clinicians seeking to mo-
bilize family members or friends to assist in an individual’s mental health treatment.
Video 6 explores the role of the patient’s family in her life.
Video Illustration 6: The family (2:35)
In this video, the clinician is conducting the core CFI with a woman with post-
partum depression who is quite engaged with the interviewer despite her ob-
vious low mood. The video starts when the clinician is exploring the patient’s
supports (core CFI question 6). The patient describes the important role that
her family members play in her social network. Her sense of belonging to her
family is strong: “They’re awesome, I love them. They come, they visit, they
bring me food, they take care of the baby.” She does not feel alone. Yet, the next
question, on stressors, reveals the pressure she feels to fulfill her role as a fam-
ily member. She fears her lack of a job outside the house will “drive us apart”
given the more limited money to “meet the new demands” of the newborn. De-
spite their closeness (“They are my life”), she doubts her family’s support will
continue if they discover her postpartum depression: “I worry about my fam-
ily and how they will react.... I don’t know if I can tell them about what I am
going through. That is probably the hardest part. What are they going to think
of me? Are they going to judge me?” The questions on cultural identity high-
light the terrible toll of her depressive illness, as it threatens the most important
aspect of her identity, which is wrapped up in her intimate social network. It is
clear from these initial questions that there are other aspects of her family rela-
tionships to explore.
The Social Network supplementary module could be very useful in this case.
In particular, it is important to identify who among her relatives are the ones
she trusts the most, whom she has told about her situation, whom she has not,
and why. Asking directly what each key individual knows about depressive ill-
ness, their understanding of the problem, and what they think should be done
about the situation would provide the clinician with essential data to help mo-
bilize the patient’s social network supports. In addition, exploring the types of
advice the patient has received from her family is important to help decrease
her anxiety and fear of stigmatization, for example, by first enlisting the help
of some relatives rather than others. Inquiring about how the family makes the
situation better or worse would help clarify how the social network would be
most helpful in relieving her distress. Finally, learning about the family’s ex-
pectations of treatment—and other forms of help seeking—is crucial for treat-
ment planning.

There are several entry points to the Social Network supplementary module. First, the
clinician may become aware of social network–related information during administra-
tion of the core CFI (see Appendix A), particularly questions 5, 6, 12, and 15 (e.g., ques-
tion 6: “Are there any kinds of support that make your [PROBLEM] better, such as
support from family, friends, or others?”). The Social Network module can then be used
in the same session or during a follow-up session to explore these issues further. Sec-
ond, the clinician may choose to use the social support module when issues arise at any
point over the course of treatment. The clinician can administer the module in its en-
tirety or use only selected questions. Finally, other supplementary modules may also be
relevant to the assessment of specific social network issues, such as the Psychosocial
Stressors module (see subchapter on supplementary module 4) and the Spirituality, Re-
ligion, and Moral Traditions module (see subchapter on supplementary module 5).
It is important to ask the first set of questions in the Social Network module to
identify whether a patient acknowledges having a social network. If no significant so-
cial networks are identified, the clinician and patient may decide to work together to
identify potential social networks that the patient can engage. Alternatively, a pa-
tient’s responses regarding social networks may be particularly helpful for planning
care when the patient identifies strong ties to a network, such as an immigrant com-
munity, a religious group, or a group of family members.
Immigrant networks are linked together by the similarities of their migration expe-
rience, as modulated by the characteristics of the particular immigrant group, including
those related to culture, ethnicity, gender, religion, language, and extent of discrimina-
tion. Immigrants from different ethnic or racial backgrounds can still develop strong
ties due to their common experiences (Curran and Saguy 2001). Identifying these ties
is important for developing a culturally informed treatment plan. For example, social
network members can be included as supports during crises, potentially helping a pa-
tient to avoid a costly hospitalization. Immigrants often develop important connections
to new friends, in addition to or instead of family members, as a result of the breakup
of traditional family systems due to migration (Höllinger and Haller 1990). Use of the
Social Network module can uncover these nontraditional social ties.
Supplementary Module 3: Social Network 79
Religious group membership illustrates how the structural aspects of social sup-
port can impact physical and mental health. Religious communities typically vary in
the extent to which they endorse use of mental health services; some offer alternative
assistance and healing services. The CFI can help clinicians identify the importance
of religion-related ties within a person’s social network and the extent to which they
affect his or her response to the problem. For example, patients who belong to reli-
gious organizations endorsing the view that life problems should be left in “God’s
hands” may be discouraged by their social networks from taking psychiatric medica-
tions and engaging in other forms of treatment (Bazler and Bazler 2002).
Conclusion
The exploration of social networks through the CFI has the potential to improve a
patient’s care by obtaining information about his or her social supports and ties to
cultural communities and using this information to build appropriate recommenda-
tions. The CFI approach strives for congruence between treatment recommendations
and the patient’s understandings and values, in the context of his or her social net-
work. Use of the Social Network supplementary module may contribute to research
that analyzes the influence of social networks (Shalizi and Thomas 2011). The mod-
ule also provides the opportunity to explore social determinants of mental health
disparities, which if addressed can lead to improvement for individual patients. We
encourage clinicians to use the module and provide feedback at www.dsm5.org/
Pages/Feedback-Form.aspx.
KEY CLINICAL POINTS

• The level of a person’s social support influences the pathway from stressful events
to mental illness by affecting the interpretation of the event and the behavioral and
endocrine responses.
• Exploring social networks may yield information about social supports and the per-
son’s ties to his or her cultural communities that can help the clinician develop cul-
turally appropriate clinical recommendations.
Questions
1. Why is it useful to explore the person’s social network?
2. What are the mental health advantages of belonging to a group?
3. What are some examples of types of social networks?
4. What can clinicians uncover by exploring an immigrant’s social network?
5. Why is it useful to explore the person’s social network?

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Suggested Readings
Kawachi I, Berkman L: Social ties and mental health. J Urban Health 78:458–467, 2001
Smith K, Christakis N: Social networks and health. Annu Rev Sociol 34:405–429, 2008
Psychosocial Stressors
Adil Qureshi, Ph.D.
Irene Falgàs, M.D.
Ladson Hinton, M.D.
Psychosocial stressors often play a central role in the genesis and

course of psychiatric disorders and can be basic to how patients and families experi-
ence, understand, and express mental illness. For example, a Puerto Rican woman liv-
ing in the United States who is the primary caregiver for her mother with Alzheimer’s
disease might understand her mother’s illness as a consequence of the loneliness trig-
gered by the erosion of family support and attention due to geographical fragmenta-
tion of the family and other factors (Hinton and Levkoff 1999). The meaning of the loss
of family support for this caregiver and the central role it plays in her explanatory
model of dementia may be understood in relation to familismo, a cultural construct that
emphasizes the value of close interpersonal ties and reciprocal support among imme-
diate and extended family members for health and well-being (Sabogal et al. 1987).
The core DSM-5 (American Psychiatric Association 2013) Cultural Formulation
Interview (CFI; see Appendix A in this handbook) contains several questions about
important psychosocial stressors influencing the patient’s problems (especially ques-
tions 7 and 10, but also questions 4, 5, 9, and 13). In some situations, however, the cli-
nician may want to inquire more deeply into the cultural aspects of psychosocial
stressors affecting psychiatric diagnosis and treatment. The Psychosocial Stressors
supplementary module was developed to assist clinicians in this endeavor. The objec-
tives of this subchapter are to describe the role of culture in the process of stress acti-
vation, appraisal, and management, to review the structure and content of the
Psychosocial Stressors module, and to provide guidelines on the use of the module in
psychiatric assessment and care.
Culture and Psychosocial Stressors

What may be experienced as stressful can vary considerably across cultures (Chun et
al. 2006). According to the transactional stress model of Lazarus (1993), stress occurs
81
if the demands of an event, situation, or endeavor exceed those that the individual is
able to manage. Stress can be said to occur if an individual appraises a situation as a
threat to his or her well-being and believes that he or she does not have the resources
to respond to it. Culture is essential to the process of stress activation, appraisal, and
management in several fundamental ways: 1) cultural values and meanings are fun-
damental to the appraisal process; 2) the kinds of resources brought to bear for coping
with stress may depend on cultural factors and the person’s immigration status; and
3) the frequency and nature of stressors may vary depending on a person’s history
(e.g., being an immigrant or refugee), positioning within the host culture (e.g., as a
member of a racial or ethnic minority group), and cultural background (Arbona et al.
2010; Berry et al. 1987; Lindencrona et al. 2008). An important aspect of the interpre-
tation of events as stressful is the person’s assessment of the adequacy of resources to
cope with the event. The patient’s cultural orientations and sociocultural context may
influence the types and availability of social and local community resources to deal
with stressful events.
One important example of how culture can shape the appraisal process comes
from research on individualism and collectivism (Markus and Kitayama 2010). Cited
frequently in the literature as foundational for selfhood, the dimension of individual-
ism-collectivism (sometimes referred to by the term independence-interdependence) can
help make sense of potential sources of stress and mitigating factors in the appraisal
process. For a woman with a collectivistic (interdependent) orientation, for example,
her very notion of selfhood is such that her group, however defined, is central to her
experience of self and sense of well-being. In this case, the individual’s role in life is
more likely to be ascribed rather than chosen, and fulfilling the socially defined role
may be central to her sense of well-being; conversely, not doing so can be a consider-
able source of stress (Chun et al. 2006). In contrast, individualism, or the independent
self, is characterized by achievement and differentiation of self from others, in which
each individual chooses his or her life path, and well-being is derived from individual
accomplishments, be they personal, social, or professional. In this respect, not living
up to one’s own expectations for individual achievement can be a considerable source
of stress.
The following examples illustrate the difference: An individual characterized by
a collectivistic mind-set may migrate to a new country to earn a sufficiently high in-
come to help the rest of the family; not finding a job that allows him or her to send
money home would be a source of stress, because the well-being of the family is par-
amount. Conversely, for an individual who migrates with the individualistic goal of
“making it big” to fulfill his or her own sense of success, not doing well in this respect
would be stressful because of the associated personal feelings of failure rather than
because of any impact on his or her family’s well-being.
Although the expectations of others still play an important role in the lives of
many individualistically oriented persons, the pressure to conform to the wishes of
family and community is considerably lower than in collectivistic cultures. It is im-
portant to keep in mind that individualism-collectivism can be understood as dimen-
sional and cannot simply be reduced to geography; individualists can live in highly
collectivistic cultures, and collectivists can live in cultures valuing individualism. Cli-
Supplementary Module 4: Psychosocial Stressors 83
nicians should be aware that their patients may experience stress because of their in-
ability to fulfill their social role and that this stress is not simply a function of a lack
of autonomy or individuation but may also be due to a very real threat to their well-
being. The threat does not necessarily derive from a negative response from family
(although it can) but rather stems from not fulfilling one’s social role, which is, in and
of itself, a source of stress given that a person’s value derives, in large part, from doing
his or her part within the group.
Culture influences not only the appraisal process but also the kinds and levels (i.e.,
frequency and severity) of psychosocial stressors to which people are exposed as well
as the resources that people have at hand to manage those stressors. This is highly rel-
evant for members of historically marginalized social groups, such as racial/ethnic
and sexual minorities, immigrants, and refugees. Disadvantaged social status can re-
duce the individual’s access to social, economic, and political resources and therefore
magnify stressors that commonly appear to be of low concern to majority group
members (Magaña and Hovey 2003; Revollo et al. 2011). Conversely, collectivism in
general and strong family values in particular can serve as resources mitigating
against mental health problems.
Acculturative stress is triggered by stressors generated through contact across cul-
tures. There is some debate as to whether this is strictly a “cultural” process or in-
cludes any and all aspects specific to migration (Rudmin 2003). For the purposes of
the CFI, what is important is that clinicians be aware of the different possible sources
of stress. To that end, the literature has identified the following types of acculturative
stress: perceived discrimination, intercultural contact stress (stemming from the person’s
adaptation to a new culture), cultural bereavement, and bicultural identity stress (Rud-
min 2009; van Tilburg and Vingerhoets 2007).
The subjective experience of racism and/or other forms of discrimination (e.g., as
a result of ethnicity or sexual orientation)—potential stressors that can negatively im-
pact health and well-being (Agudelo-Suárez et al. 2011; Bhui et al. 2005; Carter 2007;
Pachankis 2014)—is not solely the result of overtly hostile and active/explicit behav-
iors; more subtle, quite possibly unconscious or implicit behaviors of others also have
an impact (Dovidio 2001).
Intercultural contact stress encompasses multiple aspects of distressing culture
change that result from living in a new and different culture (Berry et al. 1987). It can
be triggered by rather banal details (e.g., differences in shop hours and public trans-
portation), more complex differences (e.g., unfamiliar language and norms for social
interaction), and even more complex adaptations (e.g., cultural values such as indi-
vidualism and collectivism).
Cultural bereavement involves the losses associated with migration, which be-
come all the more salient in the face of intercultural contact stress (Bhugra and Becker
2005). These losses frequently include language, social status, housing, natural envi-
ronment, relationships with friends and family, and the experience of “at-homeness”;
all of these losses can constitute important sources of stress.
Bicultural identity stress derives from the push-pull experience that two cultures
can exert on the individual (Benet-Martínez and Haritatos 2005). An immigrant or a
member of an ethnic minority group may be subject to the expectations of the culture
of origin to maintain cultural norms and practices and of the majority culture to inte-
grate; this is especially difficult for adolescents and youth. The youngster may need
to live two, separated, indeed mutually incompatible lives, resulting in acute stress.
For example, a teenager whose Pakistani parents are strongly identified with their
culture of origin may well hide from them that she has a “local” boyfriend, a tattoo or
piercing, and the like.
All of these stressors can potentially exacerbate existing mental health problems
and also represent important domains for psychosocial treatment. Working with pa-
tients’ resources to reduce the psychosocial stressors described in this section can help
decrease overall distress.

The Psychosocial Stressors supplementary module (provided in Appendix C in this
handbook) explores psychosocial stressors that may have a substantial impact on the
mental health of the individual. Five main questions help guide a conversation with
the patient about areas of stress that are not usually part of the diagnostic interview,
such as perceived discrimination, lack of group support, and adaptation difficulties.
For example, psychotherapists report that they do not usually address race-related is-
sues in routine practice (Maxie et al. 2006).
Given the goal of the CFI to facilitate access to the patient’s narrative about his or
her situation, the supplementary module’s instructions invite the interviewer to tailor
the specific questions to the particular patient. Interviewers are also encouraged to
match their language to that of the patient; thus, the specific wording used by the cli-
nician—whether it is the term used by the patient to refer to the stressor, the word
problem, or other wording—should be consonant with the patient’s usage.
Questions 1 and 2 elicit specific stressors that are affecting the individual. Questions
3–5 focus on understanding as well as evoking possible means for managing the patient’s
difficulties, taking into account the patient’s social and cultural context and origin.

The Psychosocial Stressors module is most relevant when the core CFI questions con-
cerning the problem definition and the causes identify prominent psychosocial con-
tributors to the problem. Indeed, this module seeks to identify and explore what
could be called exacerbating factors of the existing mental disorder or psychological
distress. To that end, it is best viewed not as a separate module but rather as one that
complements the other modules and can serve to get a better sense of multiple aspects
of the patient’s lived experience.
Because of the diversity of issues that can impact the incidence and experience of
stress, the clinician should begin by taking into consideration the following questions:
• What cultural model best describes the patient’s environment? Is it influenced by

collectivistic/interdependent values, individualistic/independent ones, or a com-
bination?
• What stressors are affecting the patient? Is his or her cultural group subject to dis-
crimination? Might the patient be facing stigma for the presented problem?
• How does the patient perceive the stress and how does he or she express it?
The clinician needs to be self-aware. An empathic approach in which the clinician

openly listens to the patient can help create the trust necessary for an accurate diagnosis.
It is worth noting that patients may be reluctant to raise certain issues, for example, those
related to prejudice and racism, out of concern that they may offend the clinician. It may
be worthwhile for clinicians to raise these issues themselves, by saying, for instance,
“Some people who are in a similar situation to yours find themselves exposed to racism
or discrimination. Would this be something you have experienced?” or “For you, as a gay
Muslim man here in the United States, what is life like?” The specific content of these
questions can be taken from the patient’s answers to the core CFI questions on cultural
identity. It is important that each patient’s interview be tailored to the stressors raised by
the patient as well as those inferred as likely by the clinician, so that the questions are spe-
cific to each individual. Research suggests that some ethnic minority patients may not be
comfortable raising issues of race and diversity with majority group clinicians (Chang
and Yoon 2011), fearing that they may be misunderstood. To that end, the questions in
the module provide clinicians with a way to broach these potentially important topics.
The following case illustrates the clinical use of the Psychosocial Stressors module.
Case Vignette
Camila, a 43-year-old woman from a rural area of Bolivia, migrated by herself to Ger-
many and presented to a mental health clinic for anxiety symptoms (e.g., trembling, dif-
ficulty sleeping, sweating). She was living in a low-income neighborhood of Frankfurt,
sharing an apartment with two other families, and working sporadically as an informal
caregiver for elderly individuals. She was markedly affected by immigration-related
stressors. Her four daughters, all under age 15 years, lived in Bolivia with her mother;
her command of German was limited; she did not have residency papers; she had been
stopped by the police on a few occasions to review her documents; and she reported
that she felt that native Germans stared at her with disapproving expressions. The ini-
tial cultural assessment revealed that Camila understood her problem as nervios
(nerves), which had gotten worse because of the constant stressors of her new environ-
ment and the migration process as a whole (Guarnaccia et al. 2003).
Because administration of the supplementary module should be tailored to each

patient, in Camila’s situation the clinician could phrase the first question of the mod-
ule as follows: “You have told me about some things that have affected your nervios,
such as your separation from your daughters. I would like to learn more about that:
Are there things going on that have made your nervios worse, such as difficulties with
being alone, finding a job, money, or something else? Tell me more about that.”
The interviewer can then proceed to elicit more detail on stressors the patient has
already mentioned, using the questions listed in the module. For example, the inter-
viewer might ask, “Have you experienced discrimination or been treated badly as a
result of your background or identity? Have these experiences had an impact on your
nervios?” Subsequent questions can continue to weave in the information already pro-
vided by the patient with the topics raised in the supplementary module: impact on
others (question 2), coping (question 3), suggestions from social network (question 4),
and additional sources of help, support, and treatment (question 5).
In this case, questions from other supplementary modules might also be useful,
such as from the Social Network module and the Immigrants and Refugees module.
Together with the information obtained through the core CFI, these questions may
lead to a deeper and more synthetic conversation with the patient, with the goal of
accurate diagnosis and more effective treatment.
Figure 3–2 illustrates how a well-crafted CFI assessment can reveal the psychoso-
cial stressors exacerbating this patient’s presented problem and possible avenues for
intervention.
Conclusion
The Psychosocial Stressors supplementary module provides clinicians with a method
for exploring cultural aspects of stressors that may be exacerbating the problem the
patient presents. Cultural influences on the perception and experience of stress are
substantial. Compared to the majority population, immigrants, refugees, and mem-
bers of cultural minorities may be subject to additional stressors and have access to
fewer resources for coping with them. The CFI questions help clinicians to explore
these important topics directly with all patients, contributing to the assessment of key
stressors in routine psychiatric practice.
KEY CLINICAL POINTS

• Cultural values such as the individualism-collectivism continuum are central to
what is experienced as stressful.
• Asking specific questions about culturally and biographically relevant stressors with
the help of the Cultural Formulation Interview can facilitate a better understanding of
the patient’s overall situation and help formulate diagnosis and treatment plans.
Questions
1. How does culture impact the perception of stress?
2. What are some subtypes of acculturative stress?
3. How might a collectivistic cultural mind-set influence how a person experi-

ences stress differently from someone with an individualistic mind-set?
4. How does disadvantaged social status impact the process of stress activation,
appraisal, and management?
5. How does the clinician's own cultural background affect the assessment of ac-
culturative stress with an immigrant from a cultural minority group?
Supplementary Module 4: Psychosocial Stressors
SES 1. Are there things
• Sharing apartment
going on that have
with two families
made your NERVIOS
• Low-paying sporadic
worse?
work
2. How are the people
around you affected by
these [STRESSORS]?
• Four children in Bolivia Bolivian
• Language difficulties Immigration- woman Anxiety/ 3. How do you cope with
• Perceived discrimination related factors alone in nervios these [STRESSORS]?
• No residency permit Germany
4. What have other
people suggested
about coping with
these [STRESSORS]?
• Different religion
• Cultural concept 5. What else could be
of distress done about these
Cultural
[STRESSORS]?
factors
FIGURE 3–2. Types of psychosocial stressors affecting a patient's clinical presentation and possible CFI assessment questions.
Note. SES=socioeconomic status.
87
References
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cial antecedents. J Pers 73(4):1015–1049, 2005 15958143
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511, 1987
Bhugra D, Becker MA: Migration, cultural bereavement and cultural identity. World Psychia-
try 4(1):18–24, 2005 16633496
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orders among workers: findings from the EMPIRIC Study of Ethnic Minority Groups in
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Carter RT: Racism and psychological and emotional injury: recognizing and assessing race-
based traumatic stress. Couns Psychol 35:13–105, 2007
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therapy relationships. Psychother Res 21(5):567–582 2011 21756191
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paradigm, in Handbook of Multicultural Perspectives on Stress and Coping. Edited by
Wong PTP, Wong LCJ. New York, Springer, 2006, pp 29–53
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849, 2001
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nervios and ataque de nervios. Cult Med Psychiatry 27(3):339–366, 2003 14510098
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Suggested Readings
Berry J, Kim U, Minde T, et al: Comparative studies of acculturative stress. Int Migr Rev 21:491–
511, 1987
Chun CA, Moos RH, Cronkite RC: Culture: a fundamental context for the stress and coping
paradigm, in Handbook of Multicultural Perspectives on Stress and Coping. Edited by
Wong PTP, Wong LCJ. New York, Springer, 2006, pp 29–53
Lindencrona F, Ekblad S, Hauff E: Mental health of recently resettled refugees from the Middle
East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to
handle stress. Soc Psychiatry Psychiatr Epidemiol 43(2):121–131, 2008 18060523
Spirituality, Religion, and
Moral Traditions
David M. Gellerman, M.D., Ph. D.
Francis G. Lu, M.D.
A patient’s relationship with spirituality, religion, and moral traditions

is important to assess as part of a standard mental health evaluation for several rea-
sons. This relationship often provides meaning and purpose to life, and religious
faith, spiritual affiliations, and/or moral commitments can be essential components
of a person’s individual identity. Religious and spiritual belief systems and faith com-
munities can play an important part in transmitting culturally held values, social be-
havior, and meaning even in early stages of psychological development (Shafranke
1992).
For the purposes of the DSM-5 (American Psychiatric Association 2013) Cultural
Formulation Interview (CFI), spirituality, religion, and moral traditions are defined as
systems of meaning and practice that help the individual and his or her community
address the existential problems posed by suffering, morality, mortality, and the need
for transcendence in the face of uncertainty. These systems can contribute a general
understanding of reality in the context of human existence, similar to the concept of
a “worldview” (Nicholi 2004). Spirituality and religion are related but distinct con-
cepts. Spirituality can be defined as a personal experience or awareness of, or a rela-
tionship to, a nonmaterialistic or supernatural reality or life philosophy, whereas
religion is usually considered to be a more formal and institutionalized set of beliefs,
history, identities, and practices, often including guidance on how to achieve a spiri-
tual experience (Josephson and Wiesner 2004; Lukoff et al. 2011). In addition, some
individuals may subscribe to a system of moral reasoning and practice, also akin to a
worldview, typically connected to principles of spiritual and religious traditions yet
often experienced as a secular and philosophical guide for ethical behavior and a
“good” life. These systems are referred to as moral traditions in the CFI; for example,
it is debated whether systems such as Confucianism and Buddhism are “religions,”
because neither ascribes or promotes a theistic reality despite teachings on the nature
90
Supplementary Module 5: Spirituality, Religion, and Moral Traditions 91
of existence and the promotion of behaviors meant to attune oneself to an underlying

reality. These meaning systems include moral codes, values, systems of beliefs, and
practices that guide individuals’ everyday behavior, aspirations, and way of inter-
preting and giving meaning to illness, suffering, loss, and death—questions that are
just as important to moral traditions as they are to religious and spiritual traditions.
Exploring how these systems—whether spiritual, religious, or secular—inform an in-
dividual’s identity, beliefs, faith, and practices is essential to understanding his or her
views of illness and coping and his or her decisions about health care and help seek-
ing. The effective negotiation by patients and clinicians of alternative and sometimes
conflicting life commitments in the face of suffering to attain a joint decision-making
process constitutes an essential part of a “values-based” clinical practice as an impor-
tant complement to DSM-based diagnostics (Fulford 2005).
In the core CFI, several questions may elicit information about a patient’s spiritual,
religious, and moral traditions, including questions about supports that make the
problem better (question 6), conflicting views that may make a problem worse (ques-
tion 7), and self-coping and help seeking (questions 11–12 and 14–15). However, the
only questions that inquire specifically about “faith or religion” are questions 8–10 re-
garding cultural identity, and then only as one of several aspects of the person’s back-
ground. The Spirituality, Religion, and Moral Traditions supplementary module is
devoted to these topics, especially as they relate to the patient’s current problem and
the role of these domains with respect to stressors and supports, cultural identity, cop-
ing, and help seeking (provided in Appendix C in this handbook). In this subchapter,
we provide outline of the importance of assessing spirituality, religion, and moral tra-
ditions; discuss the supplementary module in depth, including its organization; and
illustrate the value of assessing these domains with a case vignette.
Importance of Assessing Spirituality,

Religion, and Moral Traditions
Koenig (2007) summarizes several tools to help obtain what has been called “a spiri-
tual history.” For example, FICA is a mnemonic reminding the clinician to inquire
into or listen for patients’ Faith and beliefs, the Importance of their religious or spiri-
tual lives in regard to patients’ medical care, and an indication of involvement in a
religious or spiritual Community, and then to determine how to Address spiritual is-
sues in the patients’ care, if appropriate (Pulchalski 2006). Other tools include SPIRIT,
which involves inquiring into Spiritual beliefs, Personal spirituality, Integration with
a spiritual community, Rituals, Implications for medical care, and Terminal events
planning (e.g., advance directives) (Maugans 1996), and HOPE, in which the clinician
asks about sources of Hope, Organized religion, Personal spirituality, and Effects on
medical care (Anandarajah and Hight 2001). A spiritual history allows a patient to
discuss his or her religious, spiritual, and moral beliefs, values, and practices; the
ways that these may influence or affect his or her medical decision-making process or
treatment goals; and potential sources of religious or spiritual strength or concern
(Pulchalski 2006).
Video 7 explores how the patient’s religious beliefs influence his ideas about treat-
ment.
Video Illustration 7: Bridging the gap (3:57)
This video illustrates use of the core CFI to explore the patient’s preferences for
care, which include reflecting on the role of his faith in treatment. When asked
what kinds of help would be most beneficial in addressing his anxiety, the pa-
tient discusses the frustrations of reconciling his faith and values with the types
of interventions that have been recommended so far. Most salient for the patient
is that he desires his recovery and treatment to include his religious faith. He
states clearly a desire to find a therapist who might understand his religious val-
ues and background, asking the interviewer for recommendations.
The purpose of this video is to illustrate use of the CFI as a continuous inter-
view. Therefore, the interviewer chose to postpone an answer to this direct
question and to press on with the CFI. An alternative response would be to ex-
plore at that point the patient’s preferences and expectations in working with
a therapist, completing the core CFI afterward.
The patient responded to the next CFI question by highlighting the discrepancy
between his mother’s stated positive response to the suggestions of family and
friends for managing her own illness and their actual lack of effectiveness. He
says, “If anything, she just pretended like they worked outside of the home, and
she would just be in bed all day.” As a result, the patient indicates a reluctance to
talk to his family and friends about his anxiety, although it is unclear whether
this is because of perceived stigma and shame or because he expects similar un-
helpful advice. This is very useful information for the clinician in helping the pa-
tient decide what treatments to pursue: the clinician could explore the nature of
these unhelpful suggestions at that point or he could return to this issue after
completing the core CFI. Likewise, considering the importance of the patient’s
faith in the patient’s care and his previously stated preference for spiritual coun-
seling, another reasonable follow-up question would be to explore whether the
patient has discussed his anxiety with a leader in his faith and whether this
helped or possibly exacerbated his anxiety. This approach could involve inte-
grating questions from the supplementary module Spirituality, Religion, and
Moral Traditions at this point in the core CFI.
The video concludes with the last question of the core CFI, regarding concerns
about doctors and patients misunderstanding each other because of differing
backgrounds. The patient resumes discussing his struggle between under-
standing and appreciating his therapist’s recommendations to address his anx-
iety symptoms, on the one hand, and his preference to base his recovery on his
religious faith and to avoid medications, on the other. He indicates feeling
pressured by providers to take medications in contrast to his values, as well as
having many questions and doubts regarding the use of medications in gen-
eral. The patient concludes by expressing a preference to discuss his treatment
options with someone who has had similar experiences and has made progress
in his or her own recovery, consistent with the patient’s early preference for a
therapist who might share his religious values. A follow-up interview with the
Spirituality, Religion, and Moral Traditions module and the Coping and Help
Seeking module could be very useful at this point.
The role of religious, spiritual, and moral factors in assessing suicide may be espe-
cially important, because many religions discourage or prohibit self-harm (Gearing
and Lizardi 2009). In a study of depressed patients in hospitals, those patients endors-
ing religious affiliation were less likely to have a history of suicide attempts and had
lower suicidal ideation (Dervic et al. 2004). A similar finding was reported among in-
patients diagnosed with depression who reported childhood abuse (Dervic et al. 2006).
Depressed inpatients with lower scores on a scale of moral objections to suicide had
more lifetime suicide attempts and endorsed religious affiliation less often than inpa-
tients with higher scores on the scale of moral objections to suicide (Lizardi et al. 2008).
Asking whether patients’ faith or their religious, spiritual, or moral affiliation has
changed over time may reveal key experiences in their lives, such as suffering due to
trauma exposure. Individuals with posttraumatic stress disorder (PTSD) were more
likely than individuals without PTSD to report changes in spiritual or religious beliefs
(Falsetti et al. 2003). Fontana and Rosenheck (2004) assessed changes in religiosity over
time in over 1,000 combat veterans being evaluated for PTSD, many of whom had en-
dorsed religion as a “source of comfort” prior to military service. Whereas 24% reported
that religion had become a greater source of comfort over time, 29% indicated the oppo-
site. Thus, religiosity or spirituality may help some veterans cope with trauma, but for
others the experience of trauma and/or the development of PTSD may result instead in
a reduction in their sense of themselves as religious, spiritual, or moral persons.

The Spirituality, Religion, and Moral Traditions supplementary module assesses four
domains:
• Spiritual, religious, and moral identity (questions 1–4)

• Role of spirituality, religion, and moral traditions in the individual’s life (ques-
tions 5–8)
• Relationship to the current problem (questions 9–12)
• Potential stresses or conflicts related to spirituality, religion, and moral traditions
(questions 13–16)
Each domain is described below. The first domain is also described in “Aspects of
Cultural Identity Related to Spirituality, Religion, and Moral Traditions.”
Spiritual, Religious, and Moral Identity

Question 1 asks patients whether their religion, spirituality, or moral tradition is an
important aspect of their lives. Subsequent questions explore a patient’s connection
to a group associated with that particular tradition (question 2); the religious, spiri-
tual, and moral tradition background of his or her family (question 3); and any other
spiritual, religious, or moral traditions that the patient may identify with or partici-
pate in (question 4). These questions contribute to a basic spiritual history.
Role of Spirituality, Religion, and Moral Traditions

in the Individual’s Life
Questions 5–8 inquire about the role of these traditions in the patient’s and his or her
family’s life, specifically in their activities. The United States is home to a diversity of
religious faiths (Koenig 2007). Many Americans endorse belief in a God, pray, and
regularly attend a church, temple, or other religious institution. Spiritual, religious, or
moral practices may include limiting or prohibiting the eating of meat, drinking of al-
cohol, or use of particular drugs or medications, as well as encouraging fasting dur-
ing specific times of the year. Numerous studies have found associations between
religiosity and positive mental health outcomes, although the means of measuring re-
ligious behaviors and the strength of the association vary substantially (Koenig 2007).
Individuals who follow the prohibitions with respect to alcohol and drugs are obvi-
ously at lower risk for substance use disorders. In one recent study, frequency of
church attendance was associated with decreased incidence of depression onset,
whereas frequency of prayer was associated with decreased severity of depression in
older adults (Ronneberg et al. 2014).
Relationship of Spirituality, Religion, and Moral

Traditions to the Problem
Questions 9–12 examine the degree to which one’s faith, spirituality, moral tradition,
and participation in a religious community are sources of strength or coping in regard
to the problem presented. Pargament et al. (2000) examined various ways in which
patients use religious or spiritual beliefs to find meaning in times of suffering or ill-
ness. Examples of helpful or positive coping strategies included perceptions of spiri-
tual support and guidance, congregational support, and reframing of negative life
events within the conception of a still benevolent God. Negative coping strategies re-
lated to poorer outcomes included spiritual discontent, either with the congregation
or with God, and perceiving negative life events as God’s punishment (Pargament
and Brant 1998). In a related study, positive religious coping strategies predicted in-
creases in stress-related growth, spiritual outcomes, and cognitive functioning at fol-
low-up, whereas negative coping methods predicted declines in spiritual outcomes
and quality of life, as well as increased depressed mood and decreased independence
in daily activities (Pargament et al. 2004).
In the United States, clergy have been described as de facto mental health coun-
selors for some individuals because they offer a substantial amount of pastoral coun-
seling (Weaver 1998). A study of 99 African American pastors in New Haven,
Connecticut, revealed that participants averaged over 6 hours a week in pastoral
counseling, with about 20% of pastors spending over 8 hours a week in this activity
(Young et al. 2003). Similarly, a study of Muslim imams in the United States found
that 50% devoted 5 hours a week to counseling, whereas 30% spent 6–10 hours a week
in counseling (Ali et al. 2005). Asking the patient about past or current counseling
with his or her religious or spiritual teacher, pastor, or leader may reveal resources
and specific religious or spiritual practices that can be incorporated or negotiated as
part of the patient’s care.
The roles of religion and spirituality among African American women suffering
domestic violence have been examined in several studies. Most African Americans
identify themselves as Christian (Miller 2007; Potter 2007), and participation in wor-
ship serves not only as a means of religious experience and of establishing a sense of
community, but also as a venue for speaking against oppression and seeking social
justice and freedom (Miller 2007). In one study of 40 African American women who
had experienced intimate partner violence (Potter 2007), relying on religious or spir-
itual faith to cope with or end the abusive relationship was a prevalent theme.
Meditation and other Buddhist spiritual practices are key ways in which popula-
tions attempt to recover from and cope with psychological distress such as trauma
and PTSD (Nickerson and Hinton 2011). Ideally, the clinician can encourage the pa-
tient to use these resources in recovery, and certain aspects of these religious prac-
tices—from specific techniques to proverbs and imagery used in the tradition—may
be integrated into the clinical therapies to make them more culturally sensitive. For
example, among Buddhist patients, loving-kindness meditation and breath-focused
meditation may be supported and taught in the clinic setting (Hinton et al. 2013). By
assessing the patient’s use of religious and related traditions in dealing with the prob-
lem, the clinician can optimize treatment and increase empathy.
Potential Stresses or Conflicts Related to Spirituality,

Religion, and Moral Traditions
Questions 13–16 explore conflicts that may arise between one’s spiritual, religious, or
moral identity and the clinical problem or other aspects of one’s cultural identity (e.g.,
sexual orientation and gender identity). Question 13 asks whether issues related to
one’s spirituality, religion, or moral tradition contribute to the clinical problem,
whereas questions 14–16 ask more specifically about personal challenges, discrimina-
tion, and conflict with others as a result of spiritual, religious, or moral commitments.
Video 8 demonstrates the conflict between the patient’s religious upbringing and
his current suicidal thoughts.
Video Illustration 8: Crisis of faith (3:54)
The video begins as an interviewer is asking the last questions of the Spirituality,
Religion, and Moral Traditions supplementary module of a young man in the
emergency department who is struggling with thoughts of suicide. When asked
about practices related to his Catholic faith that might be helpful for his predic-
ament, the patient indicates that while at one time he felt God listened to his
prayers, this is no longer the case. At this point in the interview, it might have
been useful to explore the patient’s prior religious experiences in prayer and
how and when he began not to feel heard by God. As the interviewer goes on to
assess any potential stressors or conflicts related to his faith, the patient discusses
the tension between his family and the Catholic Church, on the one hand, and
his own suffering and thoughts of suicide, on the other. Instead of being a source
of support, his family’s Catholic faith is experienced as a further cause of his
alienation from them; he feels the family would simply encourage him to pray
instead of trying to understand his feelings of being “out of control.” This alien-
ation is highlighted in his response to the later question about being in conflict
with others, when he reiterates that his suffering and his ambivalence about
whether to continue living are creating emotional distance between him and his
wife and family because he feels they cannot understand his experiences.
One central conflict described by the patient is the tension between living with
intense suffering and taking his life and going to hell, which he believes is the
consequence of a mortal sin such as suicide. His assertion that his family and
church “won’t accept what it is I’m feeling right now, what it is I’m thinking
about,” communicates his sense of isolation. We cannot assume that his Cath-
olic faith will be a protective factor against suicide; it seems to be acting just as
much as a significant source of stress and alienation.
Conflicts between aspects of a person's cultural identity do not necessarily lead to

marked distress and impairment. For example, although many Western mainstream
religions discourage, forbid, or even oppress homosexuality, Tan (2005) examined the
“religious well-being” and “existential well-being” of 93 gay and lesbian individuals
in the American Midwest and found that respondents endorsed high levels of both
types of well-being. García et al. (2008) reviewed the challenges faced by gay, bisex-
ual, and transgender (GBT) individuals in the United States whose sexual orientation
conflicted with their religious upbringing and faith, especially among Latino men
raised Catholic. Despite endorsing conflict between their sexual orientation and Ca-
tholicism, all GBT men described reconciling their religious faith and their sexuality
to some degree, whether they remained Catholic, converted to another faith, or did
not identify any formal religious or spiritual affiliations. Many who did not identify
with a particular group described continuing to believe in God, pray, or read books
on spiritual development.
Spiritual and religious factors in men diagnosed with HIV and AIDS have also
been examined. HIV infection can exacerbate the sense of alienation from the church,
and in Miller’s (2005) sample of interviewees, many African American gay men with
AIDS left their religious institutions as a result. Seegers (2007) noted that the gay men
infected with HIV in her study endorsed an active and valued spiritual life and reli-
gious practices and expressed their spirituality through church-related activities;
however, none had openly revealed their homosexuality or shared their HIV status
with their clergy or church community. Thus, when evaluating gay, lesbian, bisexual,
and transgender patients, clinicians also need to ask about how their religious, spiri-
tual, and moral beliefs affect their feelings about their sexuality and their participa-
tion in a spiritual community.

Case Vignette
Matthew is a 27-year-old non-Latino white man who presented to the local Veterans Af-
fairs hospital for treatment of PTSD and chronic pain. He had been deployed to Iraq
during Operation Iraqi Freedom, engaged in combat, and been discharged after suffer-
ing injuries from an improvised explosive device. In his spiritual history, Matthew
identified as Roman Catholic (question 1), having been raised primarily by his Catholic
grandmother and attending mass with her until he joined the U.S. Army at the end of
high school (questions 2–3). Since returning from Iraq, he had not returned to church or
participated in services (questions 5–6). Although he wanted to attend mass with his
wife, he could not tolerate being among large groups of people, and therefore he was
concerned about missing out on an important practice of his faith (question 8). He en-
dorsed praying regularly at home (question 7) and reading the Bible (question 11) but
felt unsure that God heard his prayers (question 12). When asked if his Catholic faith
was a source of comfort or strength for him, he replied that despite his frequent wish to
be dead and thoughts of killing himself, his belief that suicide is a sin kept him from
acting on these thoughts (question 9). However, he also believed he was likely to go to
hell after he died anyway, having “destroyed families” by killing enemy combatants.
In discussing this last point, Matthew’s therapist asked whether forgiveness was an
important concept in the Catholic faith, and the patient responded that it was. The pa-
tient then met with his local bishop (question 10), who emphasized to him God’s for-
giving nature. Although somewhat comforted, the patient noted that ultimately even if
God forgave him for having to kill people as a soldier, he was unable to forgive himself.
The dissonance between being assured of God’s forgiveness and being unable to for-
give himself remained a constant challenging theme in his mental health care (ques-
tions 13–14). Matthew subsequently engaged in group psychotherapy with another
therapist, who was a Protestant and who at one point commented, “God is not in the
Catholic Church.” The patient was very offended by this remark (questions 15–16) and
dropped out of group therapy. Although the patient was able to restart individual ther-
apy with a new therapist, the insensitive comment by the former therapist precipitated
a serious setback in the patient’s mental health care.
This case illustrates several issues related to spirituality, religion, and moral tradi-
tions. It is important to highlight that although Matthew did not belong to a U.S. ra-
cial or ethnic minority group, a culturally sensitive approach to his care was very
valuable in understanding his perception of the problem and his coping and help-
seeking choices because his religious affiliation was a central component of his cul-
tural identity. Obtaining a spiritual history and trying to understand a person’s faith
and the role this may play in care can identify possible areas of dissonance, distress,
and cognitive distortions related to spirituality, religion, or moral commitments. Al-
though Matthew considered his faith an important aspect of his identity and a guide
to understanding the world, his experiences of trauma reduced his ability to practice
his faith, to be part of his religious community, and to feel close to God. In this case,
consultation with a local religious leader was an appropriate help-seeking choice for
the patient, although it ultimately did not provide the reassurance that he hoped for.
Finally, the group therapist’s lack of empathy and insensitive remark highlight the
importance of culturally competent care and the risk of harm when a person’s spiri-
tual, religious, or moral traditions are ignored or, in this case, insulted.
Conclusion
Given the prominent role of spirituality, religion, and moral traditions in the values,
attitudes, and beliefs of different cultural groups, the supplementary module on these
domains can help clinicians obtain a useful spiritual history. Routinely assessing this
kind of information provides insight into the patient’s personal coping and social re-
sources and allows the patient to express beliefs about existential meaning that may
contribute to his or her perception of the problem presented. With practice, care, and
respect, clinicians can become increasingly comfortable with obtaining spiritual his-
tories. This evaluation adds minimal time to the session and can greatly enhance the
clinician-patient relationship and increase therapeutic impact. Clinicians may choose
to administer the supplementary module as a separate element of the evaluation to
systematically assess these key domains. Alternatively, clinicians may weave ques-
tions about spirituality, religion, and moral traditions into their assessment of pa-
tients’ illness representations, developmental history, and cultural identity. Clinicians
may also find it useful to discuss patients’ level of comfort with the clinician’s stated
or divined religious beliefs, including as part of the evaluation of the patient-clinician
relationship. Attention to the role of spirituality, religion, and moral traditions in the
patient’s life is an important component of a comprehensive clinical evaluation.
KEY CLINICAL POINTS

• The routine assessment of a spiritual history allows a patient to discuss his or her
religious, spiritual, and moral beliefs, values, and practices; the ways in which
these may influence or affect his or her medical decision-making process or treat-
ment goals, personal coping, and social resources; and potential sources of reli-
gious or spiritual strength or concern.
• The Spirituality, Religion, and Moral Traditions supplementary module provides a
framework for exploring a patient’s identity; the role of spirituality, religion, and mor-
al traditions in the patient’s life; possible relationships between these traditions and
the clinical problem; and any potential stressors or conflicts related to spirituality,
religion, and moral traditions.
Questions
1. How does a clinician initially assess a patient’s religious, spiritual, and moral
traditions?
2. In what ways do spiritual, religious, and moral traditions influence decisions

about health care and other forms of help seeking?
3. How do spiritual, religious, and moral traditions contribute both adaptive and
possibly maladaptive strategies for coping with uncertainty and illness?
4. What are two spiritual or religious coping strategies that have been associated
with positive health care outcomes?
5. How can leaders or teachers of spiritual, religious, or moral traditions contrib-

ute to the patient's level of resiliency or stress in facing a clinical problem?
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George Washington Institute for Spirituality and Health: http://smhs.gwu.edu/gwish/
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Cultural Identity
This subchapter focuses on the rationale and utility of the Cultural Iden-
tity supplementary module of the Cultural Formulation Interview (CFI) and the
module’s relationship to the identity-related questions of the core CFI. The Cultural
Identity module has 34 questions presented in multiple sections (see Appendix C in
this handbook), which are grouped in this discussion as follows: 1) national, ethnic,
racial, linguistic, and migration factors; 2) spirituality, religion, and moral traditions;
and 3) gender identity and sexual orientation identity. This introductory section of-
fers a common definition for cultural identity, discusses the need for clarifying cul-
tural identity in relation to clinical practice as presented in DSM-IV and then in
DSM-5 (American Psychiatric Association 1994, 2013), and explains the core CFI and
the supplementary module on cultural identity.
Monroe et al. (2000) define identity as “the idea of a sense, developed early in
childhood, of oneself as both an agent and an object that is seen, thought about, and
liked or disliked by others” (p. 420). This definition emphasizes that identity is a sense
of self that is inherent to each individual emerging in relation to others. The CFI in-
vites clinicians to discover which aspects of the self are most important for the patient,
whom the patient names as close associates, and how aspects of the self are given
meaning in relation to these associates.
The Cultural Identity module focuses on three key aspects of identity that routinely
present clinicians with difficulties during clinical evaluation. In a literature review of
publications on the DSM-IV Outline for Cultural Formulation (OCF), Lewis-Fernández
et al. (2014) found that these three specific areas related to cultural identity would ben-
efit from greater clinical attention. These three different aspects of cultural identity are
explored subsequently in this volume; the authors present the latest relevant theories
for each aspect and illustrate practical assessments through use of the CFI.
Historical Background:
From the DSM-IV OCF to the DSM-5 CFI
The core CFI differs markedly from the OCF in two significant ways. First, the CFI dif-
fers in its placement of cultural identity exploration. Clinicians were encouraged to be-
gin the OCF with questions about the cultural identity of the individual. Supporting
101
text for the OCF clarified that clinicians should note “the individual’s ethnic or cul-
tural reference groups,” “the degree of involvement with both the culture of origin
and the host culture” for immigrants and ethnic minorities, and “language abilities,
use, and preference” (American Psychiatric Association 1994, p. 843). However, clini-
cians struggled to formulate questions using these instructions (Lewis-Fernández
2009). Psychiatric trainees have also felt uncomfortable exploring patient identities
without feeling intrusive or concerned that patients would find such questions irrel-
evant to experiences with care (Aggarwal and Rohrbaugh 2011). Therefore, members
of the DSM-5 Cross-Cultural Issues Subgroup decided to introduce questions on cul-
tural identity after the section on the cultural definition of the problem, enabling cli-
nicians to cultivate the patient trust necessary to discuss such a personal topic and to
address the most relevant and immediate patient concerns first.
Second, the CFI differs from the OCF in its treatment of cultural identity. The CFI
questions have been revised in response to theoretical innovations on culture in the so-
cial and behavioral sciences. Cultural competence initiatives in the U.S. mental health
system have historically paralleled the rise of the civil rights movements in the 1960s
that emphasized race (“African American,” “Asian,” “Native American”) and ethnicity
(“Hispanic/Latino”) as the most important markers of identity (Jenks 2011; Shaw and
Armin 2011). However, experience with such initiatives has revealed that clinicians risk
offering irrelevant recommendations on the basis of group-level racial and ethnic ste-
reotypes (Aggarwal 2011; Kleinman and Benson 2006). For this reason, contemporary
cultural competence initiatives emphasize that all people, not only racial and ethnic mi-
norities, create distinct cultures in an ongoing and dynamic process of meaning-making
based on their social affiliations (Aggarwal 2010; Carpenter-Song et al. 2007).
Cultural theorists have called attention to the notion of hybridity—that is, the idea that
all people belong to multiple subcultures at any given time—challenging the notion that
identities are only inherited, static in time, and group based rather than acquired, adapt-
able, multifaceted, and individualized (Bhabha 1994). For example, different situations
may determine whether language, ethnicity, gender, or any other social affiliation is im-
portant at any given time. The task for a clinician is to help a patient explore which affili-
ation is essential to the experience of health care at a particular point in time. Moreover, a
patient and clinician relate to each other’s hybrid identities in any number of ways, often
without awareness at the start of the clinical encounter, and these relationships influence
how the patient shares his or her cultural identity (Aggarwal 2012). An open inquiry into
cultural identity is all the more important in this era of information technology and glo-
balization in which patients and clinicians can accumulate cultural affiliations through
unprecedented travel to new societies both in person and over the Internet (Kirmayer
2006). This stance is not intended to suggest that group identities are unimportant but in-
stead it intended to promote direct inquiry by clinicians about which group identities are
most meaningful for patients rather than making assumptions.

The CFI is a patient-centered approach; it encourages clinicians not to make any as-
sumptions about patient identities. The core CFI’s approach to cultural identity has
Supplementary Module 6: Cultural Identity 103
already been introduced in Chapter 2, “The Core and Informant Cultural Formula-
tion Interviews in DSM-5.” Therefore, the focus in this subchapter is on the Cultural
Identity supplementary module. The Guide to Interviewer for the Cultural Identity
module (see Appendix C) notes the following:
We use the word culture broadly to refer to all the ways the individual understands his
or her identity and experience in terms of groups, communities or other collectivities,
including national or geographic origin, ethnic community, racialized categories, gen-
der, sexual orientation, social class, religion/spirituality, and language.
The CFI encourages clinicians to expand their understandings of identity beyond

race, ethnicity, and language preferences to include the communities to which pa-
tients belong. The introduction to the “Role of Cultural Identity” in the core CFI for
the individual being interviewed follows a similar format to the Guide to Interviewer
in adopting a patient-centered approach to identity that makes no prior assumptions:
Sometimes, aspects of people’s background or identity can make their [PROBLEM] bet-
ter or worse. By background or identity, I mean, for example, the communities you belong
to, the languages you speak, where you or your family are from, your race or ethnic
background, your gender or sexual orientation, or your faith or religion. (American
Psychiatric Association 2013, p. 753)
The Cultural Identity supplementary module includes 34 questions that cover dif-
ferent aspects of identity. Clinicians may not need to use all questions with every pa-
tient but may find these sample questions helpful for investigating specific aspects of
identity that may serve as a clinical focus. There are three main sections on cultural
identity and a final section on how this information relates to the problem presented
by the patient.
National, Ethnic, and Racial Background;

Language; and Migration
The first seven questions of the module focus on an individual’s national, ethnic, and
racial background. National, ethnic, and racial identities are forms of social affiliation
that have long been rooted in geography, with the understanding that a particular
cultural group resides in a territorially constrained area (Gumperz and Cook-
Gumperz 2008). These questions explore the birth locations of the patient and family,
definitions of cultural community, the contexts in which these definitions arise, and
the extent of any current health or life problems due to identity. These questions may
be clinically useful when national, ethnic, and racial issues are defining features of the
patient’s presentation, as detailed subsequently in “Aspects of Cultural Identity Re-
lated to National, Ethnic, and Racial Background; Language; and Migration.”
Questions 8–13 in the module uncover information about language, including flu-
ency, situations in which certain languages are preferred, and preferences for lan-
guage use in health care settings. Anthropologists have increasingly shown that
language is not constrained within geographical borders (Urciuoli 1995); therefore, a
clinician should not assume that all patients speak his or her language without first
inquiring into their preferences. Clinicians may find these language questions helpful
when the patient seems to express difficulties in speaking the dominant language of
the clinic and would prefer interpreters.
Questions 14–22 on migration explore the circumstances of leaving a birth coun-
try, challenges of acculturation, and the impact of these factors on a patient’s current
presentation. Clinicians who treat immigrant and refugee populations may find these
questions especially pertinent, especially because legal status may affect the extent to
which patients decide to access health services.
Spirituality, Religion, and Moral Traditions

Questions 23–25 pertain to spirituality, religion, and moral traditions. They are posed
to obtain information on specific beliefs and practices that inform the current illness
and life in general, as discussed in “Aspects of Cultural Identity Related to Spiritual-
ity, Religion, and Moral Traditions.” Clinicians may find that answers to these ques-
tions illuminate existential concerns raised by the current episode of sickness and
indicate how patients continually derive meaning from their suffering throughout the
experiences of illness and healing.
Gender and Sexual Orientation Identity

Questions 26–28 on gender identity and questions 29–32 on sexual orientation iden-
tity inform clinicians about the patient’s identifications and their impact on the illness
experience and general access to services. As explained in “Aspects of Cultural Iden-
tity Related to Gender Identity and Sexual Orientation Identity,” stigma and discrim-
ination have long acted as barriers to care for populations with gender and sexual
orientation identity issues, and the CFI Cultural Identity module can inform clini-
cians about such potential barriers in formulating better alternatives for the current
clinical encounter.
Summary
The supplementary module ends with two open-ended summary questions (ques-
tions 33 and 34). They seek information about other aspects of identity that might
help the clinician better understand the patient’s health care needs and about which
aspects of identity are most important in relation to the current problem.
Conclusion
The questions on cultural identity in the core CFI and the supplementary module are
intended to help clinicians develop practical, patient-centered approaches for diag-
nostic assessment and treatment planning. The DSM-5 field trials have demonstrated
the need to translate theories from the social sciences for practical clinical care (Ag-
garwal et al. 2013). Case reports, controlled studies, and the experiences of clinicians,
researchers, patients, and administrators can provide valuable information about
how the developers of the CFI and its supplementary modules have succeeded and
Supplementary Module 6: Cultural Identity 105
where revisions are needed for future editions of DSM. For example, experience with
these supplementary modules may point to aspects of identity that seem most rele-
vant to clinical situations. By the same token, clinicians may find that the supplemen-
tary modules include too much information for practical use. Because virtually no
information is available on what patients deem important to ask regarding cultural
identity, various stakeholders are invited to treat these supplementary modules as
works in progress that elucidate how cultural identity relates to sickness and health.
KEY CLINICAL POINTS

• People adopt different identities based on social relationships, suggesting that cli-
nicians need to ask patients how they identify rather than making general assump-
tions.
• The core Cultural Formulation Interview and its supplementary modules contain
practical questions to address the relevance of a patient’s identity to the problem
he or she presents.
Questions
1. How is culture defined in DSM-5?
2. How does culture affect the care of patients in clinical practice?
3. What types of barriers to care do immigrants and refugees experience?
4. What types of barriers to care do people with gender and sexual orientation
identity issues experience?
5. Why should patients be asked about their spiritual, religious, or moral tradi-
tions?
References
J Am Geriatr Soc 58(11):2191–2196, 2010 20977437
Aggarwal NK: Intersubjectivity, transference, and the cultural third. Contemp Psychoanal
47:204–223, 2011
Aggarwal NK, Rohrbaugh RM: Teaching cultural competency through an experiential seminar
on anthropology and psychiatry. Acad Psychiatry 35(5):331–334, 2011 22007094

Bhabha H: The Location of Culture. New York, Routledge, 1994
Carpenter-Song EA, Nordquest Schwallie M, Longhofer J: Cultural competence reexamined:
critique and directions for the future. Psychiatr Serv 58(10):1362–1365, 2007 17914018
Gumperz JJ, Cook-Gumperz J: Studying language, culture, and society: sociolinguistics or lin-
guistic anthropology? Journal of Sociolinguistics 12:532–545, 2008
Jenks AC: From “lists of traits” to “open-mindedness”: emerging issues in cultural competence
education. Cult Med Psychiatry 35(2):209–235, 2011 21560030
Kirmayer LJ: Beyond the ‘new cross-cultural psychiatry’: cultural biology, discursive psychol-
Lewis-Fernández R: The cultural formulation. Transcult Psychiatry 46(3):379–382, 2009
19837777
Monroe KR, Hankin J, van Vechten RB: The psychological foundations of identity politics. An-
nual Review of Political Science 3:419–447, 2000
Shaw SJ, Armin J: The ethical self-fashioning of physicians and health care systems in culturally
appropriate health care. Cult Med Psychiatry 35(2):236–261, 2011 21553151
Urciuoli B: Language and borders. Annu Rev Anthropol 24:525–546, 1995
Suggested Readings
Cerulo KA: Identity construction: new issues, new directions. Annu Rev Sociol 23:385–409,
1997. A good review of how social scientists such as anthropologists and sociologists think
about cultural identity.
try 46:383–405, 2009. Explanation of how social science theories can be used to explore cul-
tural identity through the cultural formulation.
Aspects of Cultural Identity Related
to National, Ethnic, and Racial
Background; Language;
and Migration
Simon Groen, M.A.
Hans Rohlof, M.D.
Ton and Lim (2006) define cultural identity as follows:
a multifaceted core set of identities that contributes to how an individual understands

his or her environment. Ethnic identity is often a crucial facet of an individual’s overall
cultural identity, but many other facets may contribute to it as well. The greater the
amount of detail a clinician is able to ascertain about the individual’s cultural identity,
the better understanding he or she will have of the individual’s perspectives on health,
illness, and the mental health system. (p. 10)
The Cultural Identity supplementary module (provided in Appendix C in this

handbook) of the Cultural Formulation Interview (CFI) offers an opportunity for cli-
nicians to explore the complexity of patients’ cultural identity by unpacking its vari-
ous elements. Here, in addition to evaluating the problem presented, we examine the
first three parts of the module in an attempt to explore clinical relevance with respect
to identity: national, ethnic, and racial background; language; and migration. Finally,
we provide suggestions on how to use this portion of the module.
National, Ethnic, and Racial Background

Questions 1–7 of the Cultural Identity module ask about the patient’s national, ethnic,
and racial background.
National Identity
National identity expresses the feeling of difference one person has from another based
on the conceptualization that they belong to different nations or to distinct national
107
groups within a multicultural setting (Smith 1993). When clinicians elicit the national
identity of individuals with mental health problems during diagnosis and treatment,
they may need to be aware of the patient’s sense of belongingness, which could in-
clude the patient’s relationship to national symbols, language(s), the nation’s history,
national values, politics, religions, national media, music, food habits, and so on. The
awareness of difference is addressed by the question “Who are we?” as opposed to
“Who are they?” Anderson (1983) introduced the concept of nation as a socially con-
structed imagined community as conceived by the persons who believe themselves
to be a part of that community. The community is “imagined” because “the members
of even the smallest nation will never know most of their fellow members, meet them,
or even hear of them, yet in the minds of each lives the image of their communion”
(Anderson 1983, p. 49). It is important to bear in mind that national, geographical, and
cultural boundaries are not coterminous.
For the clinician, it is useful to explore the individual’s notion of that imagined
community. A nation’s history and the everyday values prized by the group have de-
veloped over time, and this history plays a major role in the sociocultural construc-
tion of the national identity of its community members. Cases in point are the
dramatic sociohistorical changes after the independence of formally colonized na-
tions in Africa and Asia in the 1960s, the Islamic Revolution in Iran in the 1980s, and
national development of former Soviet satellite states in the 1990s. There are also
more distant events, such as the origin of the United States as a nation in the struggle
against the British and the historical development of Latin American countries op-
posed to Spanish rule. In psychoanalytical literature, this is known as large-group iden-
tity, which is based on chosen victories and chosen traumas (Volkan 1999). A clinician
does not have to be aware of the entire historical development of a patient’s nation or
community. However, when the clinician is eliciting a patient’s national background
(questions 1–6), understanding the historical context is helpful for eliciting his or her
life story in a culturally sensitive manner.
Place of birth is an important aspect of identity (question 1). Cultural differences
based on regional distinctions are common. For instance, if a patient is born in Iraq, it
matters whether he or she is from Baghdad, Kirkuk, or Basra. Baghdad has a multi-
ethnic population that is mainly divided into Sunni and Shiite districts. In the current
moment, Baghdad is a city with frequent ethnic conflicts, car bombings, and other
forms of violence. Kirkuk, a city in northern Iraq, is economically one of the most im-
portant municipalities in the autonomous region of Kurdistan, mostly populated by
Iraqi Kurds. Basra is the most important city in the Shiite-dominated southeastern
part of Iraq that was heavily involved in the Iran-Iraq War from 1980 to 1988. The dif-
ferences between these various localities may be more important to the patient at
times than their commonalities as part of the more recent nation-state of Iraq.
In Europe, many immigrants were born in the former Yugoslavia, the Punjab, or
Bengal before geopolitical partitions, and these places of origin have evolved over
time both politically and culturally. As another example, if someone is from the south-
ern Indian state of Tamil Nadu, it may be relevant to establish whether the patient is
of Tamil or Sinhalese origin from Sri Lanka, because this fact may provide clues to so-
cial exclusion or experiences of military trauma and genocide. In many countries, ur-
National, Ethnic, and Racial Background; Language; and Migration 109
ban and rural areas differ in important ways. This is the case in many African nations:
rural areas have less access to mental health care; different knowledge of psychopa-
thology; and variation in adherence to indigenous belief systems, secret societies,
witchcraft, ideas about ghost or spirit possession, and other supernatural concepts.
In many countries, especially those populated by diaspora cultures, identity is
shaped by parental place of birth (question 2). If one or both parents were born in
another nation or culturally distinct area, this often influences a person’s identity. A
Chinese American man whose parents were born in China and who himself was
born in California may see himself more as Chinese at times or more as American
at times, depending on the context. If the parentage is mixed, especially if parents
are from areas in conflict with each other, such as individuals of Bosnian-Serbian or
Azeri-Armenian heritage, this can pose substantial challenges: these individuals
run the risk of being rejected, threatened, or even chased and murdered by those
whose parentage is not mixed.
As these examples show, identity is an active process of representing oneself to
others. Someone’s place of birth (question 1), parentage (question 2), and national, eth-
nic, and/or racial background (question 3) play important roles in self-representation
in everyday life—that is, how that person describes himself or herself to others (ques-
tion 4).
Ethnic Identity
Ethnicity refers to the classification of people as belonging to a group that claims a
common descent, frequently attributed to a specific geographical region; usually a
common language and other cultural characteristics; and possibly a common religion
(Eriksen 1993). Such group identities are always defined in relation to nonmembers
of that group (Barth 1969). Ethnic groups within a nation may differ from each other
in terms of primary language, religion, rituals, values, symbols, clothing, and food.
Of course, within ethnic groups, subgroups also vary in terms of these characteristics,
but the point of the concept of ethnicity is that it minimizes these particular differ-
ences in the name of the postulated group similarities. For example, Puerto Ricans
may speak English or Spanish as their primary language, depending on the extent
and duration of their U.S. migration experience, but this difference is minimized in
the name of a common Puerto Rican ethnicity. A nation may contain multiple ethnic
groups; for instance, Ethiopia has more than 80 such groups. Alternatively, an ethnic
group may span more than one currently defined nation-state; the Kurds, for exam-
ple, live in parts of Iraq, Turkey, Iran, and Syria. In most African countries, the word
tribe is more common than ethnic group in everyday speech. In Somalia, there is a com-
plicated clan genealogy with major clans and many subclans. Somalis may recognize
each other’s lineage by their double last names. The clan or subclan to which a Somali
belongs can influence educational and work opportunities as well as experiences of
protection and discrimination (Groen 2009). The U.S. Census distinguishes only one
ethnicity, Hispanic/Latino, and five races, white/Caucasian, black/African American,
Asian, American Indian and Alaskan Native, and Native Hawaiian and Pacific Is-
lander. The distinction of Latino-ness as an ethnicity is a recent development, stem-
ming from political recognition of the diversity of characteristics usually considered

racial that characterize the Latino group; Latinos can be of European, African, Native,
or Asian descent but are supposedly unified by their cultural similarities, including
language and Latin American geographical background. Obviously, Latinos also dif-
fer markedly from each other, underlining the primarily political aspect of the defini-
tion of ethnicity.
In some nations, there are violent conflicts between ethnic groups. For example,
there were large-scale warlike conflicts between Hutu and Tutsi in the late 1980s in
Rwanda; between Azeri and Armenians (the Nagorno-Karabakh conflict) also start-
ing in the late 1980s; and among Bosnians, Croatians, and Serbs in the former Yugo-
slavia during the 1990s. There may also be less intense conflicts between mainstream
and minority ethnic groups regarding whether or not the latter belong to the larger
national group. The Pashtun claim the Hazara are not real Afghans; other Angolans
claim the Bakongo are not real Angolans; many Congolese claim the Banyamulenge
belong to Rwanda. The position of ethnic groups varies across different states and
time periods; currently, Kurds are relatively safe in the autonomous region of Kur-
distan in northern Iraq, but they are sometimes persecuted in Iran, Syria, and Turkey.
Canadians may define their ethnic identities in terms of the complexities of their co-
lonial past; also, as a result of a common history of colonialism and foreign domina-
tion, the Irish may see themselves as a separate ethnic group but define themselves as
politically aligned with the black population in the United Kingdom.
Racial and “Racialized” Identity

The term race has no scientific or biological basis; it is instead a social construct that
acquired its modern form in the eighteenth to nineteenth centuries. Racialized identity
is an alternate social construct that highlights the point that the experience of race is
based on the perception of having a common heritage with a particular group defined
in racial terms (Helms 1993). A commonly defined racialized identity is that of skin
color. This popular folk notion often clumps people into blacks, whites, reds, or yel-
lows. Responses and attitudes toward skin color vary across and within countries. In
the United States, being part of a racialized community, such as white Americans,
American Indians, or African Americans, may play a crucial role in defining one’s
cultural identity, particularly if viewed by others as a “true” characteristic of a person.
Therefore, it is important to ask patients how they locate themselves with respect to
racialized identities prevailing within their community or culture. Many patients of
African, Asian, and Afro-Caribbean background in the United Kingdom may think
their mental health problems are misunderstood by local white British clinicians.
They may feel that they have been wrongly diagnosed or have been treated in a cul-
turally insensitive manner, which may result in poor adherence to care (Littlewood
and Lipsedge 1997). The reverse may also apply to clinicians in other countries pro-
viding consultations to local white British or white U.S. patients. In many regions,
such as in India, the term race or racial identity may not resonate with local ideas of
identity. Instead, caste (jäti) or social class may constitute the core of a person’s or com-
munity’s cultural identity. In such contexts, caste and class identity of both patient
and clinician may hinder or facilitate access to care and engagement with treatment.
Therefore, clinicians eliciting a person’s “racial background” need to be sensitive to
locally prevalent notions of “racial identity” and the manner in which these terms are
expressed and understood in different contexts and cultures (Jadhav and Jain 2012).
Videos 9 and 10 illustrate the use of the National, Ethnic, and Racial Background
section of the Cultural Identity supplementary module.
Video Illustration 9: A small town, which is why I’m here (4:39)
In the video “A small town, which is why I’m here,” a psychiatrist conducts
an interview with a middle-aged Puerto Rican man who suffers from anxiety
symptoms at work after his mother, who lives in Puerto Rico, has a stroke. The
aim of the National, Ethnic, and Racial Background portion of the Cultural
Identity supplementary module is to assess how a person’s national, ethnic,
and racial background affects his or her sense of self and his or her place in so-
ciety and how these aspects of identity influence behavior. In this video, the
clinician frames the purpose of the interview. This is an important part of any
supplementary module, because it clarifies for the patient how the subsequent
questions relate to the patient’s reason for seeking help. In this case, the inter-
viewer emphasizes that he wants to understand whether the patient’s cultural
identity influences his mental health problems and his expectations of care.
The initial questions immediately reveal the reason for seeking help. The pa-
tient is experiencing substantial anxiety because his mother is in Puerto Rico
in a town with limited access to the tertiary medical care she needs for her
stroke. He feels pressure to return to the island to provide the care she needs,
as seems to be expected of any good Puerto Rican son. In fact, if he does not
go, his family might think less of him and perhaps even repudiate him to some
extent. The conflict stems from the fact that his sense of himself is connected
to being the kind of person who takes risks to become successful, including
migrating to the United States for a better future. To complicate matters fur-
ther, he fears that he could lose his job if he responds to what he and his com-
munity in Puerto Rico interpret as his filial duty. He appears puzzled by the
reaction of his employers, who are unwilling to grant him leave from work to
travel. He says, “At work they...kinda don’t get this thing with family. I don’t
quite understand how it works over here, but it’s almost like family isn’t im-
portant, like you’re supposed to go working anyway, you can’t take any time
off.” His current predicament highlights the cultural differences between his
new environment and key aspects of his identity, and this conflict appears to
be heightening his anxiety.
Information on a patient’s cultural identity can help clarify perspective on
health, illness, and the mental health system. The way an individual represents
himself to others, how he feels about his position in society, and how this re-
lates to his mental health problems is useful information for the clinician. Start-
ing from the information obtained in the video, the interviewer can proceed to
elicit additional details. For example, the interviewer could obtain more infor-
mation on the patient’s role in his family. The clinician could ask if the patient
is the eldest son, who is thought to have a special responsibility for his mother,
or how his family reacted to his migration and to his drive to succeed, which
may put extra pressure on him that could contribute to his symptoms. To help
with the current situation at work, the clinician could inquire whether he has
felt misunderstood there in other situations, whether there are other Puerto Ri-
can coworkers, whether they have experienced the same kind of misunder-
standings, and whether he is afraid to be discriminated against as a result of
his ethnicity if he asks for unpaid leave.
Video Illustration 10: It gets kind of confusing (2:41)
In the video “It gets kind of confusing,” the interviewer explores the cultural
identity of a young woman of mixed Panamanian–U.S. descent who is being
evaluated for apparently having auditory hallucinations of her grandmother’s
voice (see the video “Full CFI” for longer segments from the complete CFI as-
sessment). The goal of this section of the Cultural Identity supplementary
module is to assess how a person’s national, ethnic, and racial background af-
fects his or her sense of self and his or her place in society and how these as-
pects of identity influence behavior. The patient calls herself “American” but is
exposed to “traditions and culture that I carry with me from the Panamanian
side of my family.” Her juxtaposing of these aspects of her background as in
some sense opposed to each other carries through the rest of the interview. Her
father is “from America” and “white,” while her mother and her relatives are
from Panama. Her mother “is a citizen now,” apparently somewhat recently.
The patient tends to resolve the conflict by telling people she is “Hispanic,” but
in general “I try to not even enter the topic.” She feels people “get confused”
about ethnicity and race in general, given that people “can be a mix of any-
thing, can be a mix of black, or white, or Native American, everything.” She
feels “like any other like American person growing up in my hometown,” but
she also feels closest to the Panamanian side of the family. This is partly be-
cause of the cultural traditions that endure in her nuclear family and also be-
cause of her close, loving relationship with a grandmother in Panama. The
interview illustrates some of the complexities of identity that may be affecting
her clinical presentation, resulting in a deep-set conflict expressed via halluci-
natory experiences. Information on her cultural identity would be essential for
her treatment going forward, for example, in certain types of psychotherapy.
The interview illustrates some of the complexities of identity that may be affecting
her clinical presentation, resulting in a deep-set conflict expressed via hallucina-
tory experiences. Information on her cultural identity would be essential for her
treatment going forward, for example, in certain types of psychotherapy. The cli-
nician could obtain more information on each of the points raised by the patient—
for example, regarding the role of cultural traditions in her household and whether
these led her to feel “different” from her peers growing up. These questions are
likely to elicit useful material for the process of psychotherapy.
Language
Questions 8–13 of the Cultural Identity module evaluate language with respect to
identity. Language is a key component of identity and serves as a marker of belonging
to a certain cultural group. Consider the following statement by an Iranian woman
from Tabriz in the province of East Azerbaijan in northeastern Iran, which is popu-
lated by Turkish, Turkmen, and Bulgarian Iranians:
As long as I know, my family has been in Tabriz. Because my parents did not have many
opportunities to go to school, they hardly spoke Farsi. We spoke Azeri at home. In pri-
mary school, until fifth grade, the books were in Farsi, but the teachers taught in Azeri.
From fifth grade on, they started to teach in Farsi. I felt I was different from others, be-
cause I was fluent in Azeri but not in Farsi. (Azeri patient from Iran seen in a Dutch
clinic)
This example shows how language influences the sense of belonging. For this
woman, speaking a certain language marks her sense of being different from others.
The language a person uses can vary across situations: at home, on the street, in
school, or in official documents. In some places during certain time periods, the lan-
guages of particular national subgroups have been forbidden in public space, such as
the Kurdish language Kurmanji in Turkey or Catalan in Franco’s Spain. People may
refrain from speaking their mother tongue in public if they are afraid to be recognized
as a member of a particular group.
After people migrate, the languages they speak at home often vary depending on
speaking partner (question 10). For instance, parents may feel most comfortable
speaking their native language with each other but may mix their language with the
language of the host country when speaking to their children. Sometimes, the chil-
dren do not learn the language of the host country until they go to school. Frequently,
the children are more fluent than the previous generation in the language of the host
nation and may have to help their parents read letters or official documents. At times,
children may forget their native language. This may pose communication problems
with their parents and also contribute to intergenerational conflicts. Parents may find
it upsetting that their children are no longer able to speak with family members left
behind in their home country and may feel that they have lost touch with their culture
of origin.
Some migrants are proud of their fluency in the host language. This may become
clear during their interaction with clinicians in mental health care (question 12). Us-
ing an interpreter in such a situation could be regarded as an insult and as a refutation
both of their progress and of their acculturation to the host country. However, when
expressing intense emotions, these patients may well be more fluent in their native
language. In such instances, a clinician could point out the benefit of speaking in the
native language but express respect for their language acquisition in the host country.
Some patients refuse an interpreter because, despite confidentiality regulations, they
do not trust other members from their cultural group, particularly when the migrant
community is composed of diverse subgroups, some of whom were in conflict in the
culture of origin. Some patients from tightly knit communities may refuse interpret-
ers because of concern over the risk of disclosure leading to stigmatizing conse-
quences for their family, including decreased marriage prospects for their children.
Alternatively, interpreter refusal may be the result of the realistic or imagined fear of
being identified and thus persecuted after escaping from their countries of origin for
cultural and political reasons. The clinician should respect and address all of these
concerns during treatment.
Language literacy may also be an important aspect of identity. For example,
whether a person can read and write in his or her native language may indicate a cer-
tain sociocultural status in the home country (question 13). For instance, many Af-
ghan women, particularly those in rural areas, are forbidden to go to school and
therefore are usually illiterate. This situation can become a major obstacle to their ef-
forts to integrate within the host country.
Migration
Questions 14–22 of the Cultural Identity module evaluate migration in relation to
identity and the problem presented. For immigrants, a major stressor is leaving
loved ones and a familiar sociocultural context and having to develop a new life in
the host country. Migration may be forced or due to personal choice. Both types re-
sult in cultural displacement and dislocation. However, migration may not always
be detrimental to the person’s health because his or her experiences are also shaped
by responses from members of the host society. Migration and postmigration living
problems—for example, those problems due to experiences in transit to the host na-
tion or events in the host nation such as the asylum procedure—may be the most im-
portant causes of distress (Laban et al. 2005). The clinician needs to know how long
the patient has lived in the host country, what was the reason for leaving the country
of origin, and how his or her life has changed as a result of the migration process
(questions 14–16). For example, for individuals originating from a collectivistic soci-
ety, adapting to a more individualistic culture might add new dimensions to their
mental health problems. Having been accustomed to the group taking care of its
members’ problems, they may feel alienated in the new setting because they are re-
sponsible for their own individual health care–seeking choices. Equally, there may
be intracultural variations among individuals from a collectivistic society, in that
some might be primarily allocentric (other focused) and others may be egocentric
(self-focused) (Bhugra 2005). For clinicians, it is important to use the Cultural Iden-
tity module to distinguish a patient’s individual characteristics and not to fall into
the trap of stereotyping on the basis of fragmented knowledge about the person’s
country of origin.

Using this supplementary module in clinical practice is best illustrated by a clinical
vignette. The vignette does not address all of the questions in the module but touches
on its key components.
Case Vignette
Amir, a 39-year-old Iraqi man who had worked as an interpreter for Western allied forces
in Iraq, was referred to mental health care in a European country for severe depressed
mood and nightmares after suffering a traumatic exposure. His most pressing concern
was that he felt his problems were not acknowledged by the government of the country
where he found refuge. He mentioned that he worked quite hard for the army of occupa-
tion. He thought it would bring him great respect. But over time, he came to feel like a
traitor to his country and had great difficulty proceeding with his life as usual. During the
early phase of treatment, the clinician and patient elaborated on what Amir meant exactly
by this statement. He explained that he hoped that by becoming an army interpreter he
would bring prosperity and freedom for his people. This idealistic view of his activities
eroded over time, as he felt increasingly that he was exploited and trapped in a power dy-
namic in which he could not participate any longer. He came to feel that he was used as
a tool for the suppression of his own people. Moreover, when Amir made a return trip to
Iraq from his host country, he was regarded as a traitor by his fellow countrymen.
He told the clinician that his family in Iraq was in great danger because of his inter-
preter work and was viewed as an enemy by the Iraqis opposing the Western occupa-
tion. When asked what he would do if they attacked his family, Amir turned very pale
and said, “I would kill myself, because it would be my fault and I would not be able to
cope with my guilt.” He stated that in his culture, family meant everything. On another
occasion, he said that he was proud to be an inhabitant of his “new” country; now he
felt that if asked to choose, he would want to remain there. This was because in Iraq he
felt physically unsafe and he would also feel controlled by his family. Amir appreciated
the possibility for further educational development and other opportunities to advance
his life because of the support he had received in his “new” country. As a result of his
conflicting feelings, his cultural, national, and ethnic identity had become intensely
mixed and chaotic.
This vignette demonstrates how national and migration issues are intertwined
with multiple aspects of cultural identity. A person’s cultural identities mutually in-
fluence and shape each other. In addition, different aspects of identity may come to
the fore depending on the context in question. This man is an Iraqi by national iden-
tity, but his work and experiences in the host country after migration changed his at-
titude toward his country of origin and his fellow countrymen. The case illustrates the
dynamic aspect of identity. What is crucial for the clinician to explore is the value a pa-
tient attaches to the various dimensions of identity and how these dimensions influ-
ence his or her sense of belonging, self-esteem, and other elements of self-experience
that are important clinically. The Cultural Identity supplementary module can help
the clinician perform a relatively thorough evaluation of identity if the clinician ap-
proaches the assessment with an inquisitive and respectful attitude in an atmosphere
of open exchange. When conducting a cultural assessment, the clinician elicits the cul-
tural aspects of the person's identity but also should not forget the position of the in-
dividual in the culture.
Conclusion
The Cultural Identity supplementary model assesses the impact of national, ethnic,
and racial background; language; and migration because eliciting a patient's multi-
faceted cultural identities helps the clinician better understand the individual's per-
spectives on his or her mental health problems. This subchapter focuses on these
issues, how they relate to mental health problems, and how they can be addressed by
clinicians.
KEY CLINICAL POINTS

• Aspects of a patient’s cultural identity related to national, ethnic, racial, and linguis-
tic background as well as migration status can affect the type and severity of risk
factors for mental health problems, the patient’s interpretation of illness causation
and symptomatology, and help-seeking expectations.
• Exploration of these aspects of cultural identity with the Cultural Formulation Inter-
view may improve patient engagement and clinician understanding of the person’s
mental health problems, especially among cultural minorities, including migrant
populations.
Questions
1. What are some of the aspects of cultural identity that can affect the onset, in-
terpretation, and care of mental health problems?
2. How can cultural identity affect the causes of mental health problems and the
person’s help-seeking choices?
3. How can language differences and migration experiences influence diagnosis

and treatment?
References
Anderson B: Imagined Communities: Reflections on the Origin and Spread of Nationalism.
London, Verso, 1983
Barth F: Introduction, in Ethnic Groups and Boundaries: The Social Organization of Cultural
Difference. Edited by Barth F. Boston, Little, Brown, 1969, pp 9–38
Bhugra D: Cultural identities and cultural congruency: a new model for evaluating mental dis-
tress in immigrants. Acta Psychiatr Scand 111(2):84–93, 2005 15667427
Eriksen TH: Ethnicity and Nationalism: Anthropological Perspectives. London, Pluto Press,
1993
tion of a Somali patient. Transcult Psychiatry 46(3):451–462, 2009 19837781
Helms JE: Introduction: review of racial identity terminology, in Black and White Racial Iden-
tity: Theory, Research and Practice. Edited by Helms JE. Westport, CT, Praeger, 1993, pp 3–8
Jadhav S, Jain S: Clinical appeal of cultural formulations in community rural mental health, in
Comprehensive Textbook on Community Psychiatry in India. Edited by Chavan BS,
Gupta N, Arun P, et al. New Delhi, Jaypee Brothers, 2012, pp 560–565
Laban CJ, Gernaat HBPE, Komproe IH, et al: Postmigration living problems and common psy-
chiatric disorders in Iraqi asylum seekers in the Netherlands. J Nerv Ment Dis 193(12):825–
832, 2005 16319706
Littlewood R, Lipsedge M: Aliens and Alienists: Ethnic Minorities and Psychiatry, 3rd Edition.
London, Routledge, 1997
Smith AD: National Identity: Ethnonationalism in Comparative Perspective. New York, Pen-
guin Books, 1993
tural Psychiatry. Edited by Lim RF. Washington, DC, American Psychiatric Publishing,
2006, pp 3–31
Volkan VD: Psychoanalysis and diplomacy: part I. Individual and large group identity. J Appl
Psychoanal Stud 1:29–55, 1999
Suggested Readings
Berry JW, Poortinga YH, Segal MH, et al: Cross-Cultural Psychology: Research and Applica-
tion. Cambridge, UK, Cambridge University Press, 2002
tion of a Somali patient. Transcult Psychiatry 46(3):451–462, 2009 19837781
Multicultural Mental Health Resource Centre: http://www.multiculturalmentalhealth.ca/
clinical-tools/cultural-formulation/
Ton H, Lim RF: The assessment of culturally diverse individuals, in Clinical Manual of Cultur-
al Psychiatry. Edited by Lim RF. Washington, DC, American Psychiatric Publishing, 2006,
pp 3–31
UCL Cultural Consultation Service: http://www.ucl.ac.uk/ccs/specialist-services
van de Vijver FJR, van Hemert DA, Poortinga YH: Multilevel Analysis of Individuals and Cul-
tures. New York, Erlbaum, 2008
to Spirituality, Religion, and
Moral Traditions
Francis G. Lu, M.D.
Spirituality, religion, and moral traditions often offer meaning and purpose to
an individual’s life, and religious faith, spiritual affiliations, and/or moral commit-
ments can be essential components of a person’s cultural identity. Religious and spir-
itual belief systems and faith communities can play an important part in transmitting
culturally held values, social behavior, and meaning even in the early stages of psy-
chological development (Shafranke 1992). Such beliefs and values may be challenged
when one’s perceived identity is threatened or distorted at times of crisis or transition
(Peteet 2004b), further contributing to a person’s distress. All of these components of
identity can influence a patient’s views and behaviors, including how the patient un-
derstands his or her psychiatric illness and how the patient chooses to navigate
among available mental health care choices (Peteet 2004a).
Assessment of Cultural Identity in

the Core Cultural Formulation Interview
and Supplementary Modules
The core Cultural Formulation Interview (CFI) has three questions on the patient’s
cultural identity (questions 8–10); “faith or religion” is indicated as a component of
this identity. These basic questions on general cultural identity are supplemented with
three additional questions in the Cultural Identity supplementary module that focus
specifically on the spiritual, religious, and moral aspects of identity (question 23); the
importance of these issues in patients’ everyday lives (question 24); and the contribu-
tion of the patient’s family to this aspect of identity (question 25). If the clinician wants
to follow up the answers to these questions, a separate module on the overall role in
the person’s life of spirituality, religion, and moral traditions lists domains and spe-
cific questions for further exploration (for more information see subchapter “Supple-
mentary Module 5: Spirituality, Religion, and Moral Traditions” and Appendix C in
this handbook).
118
Cultural Identity Related to Spirituality, Religion, and Moral Traditions 119
In the Cultural Identity module, question 23 opens a dialogue with the patient
about the aspect of his or her identity that has to do with religious, moral, or spiritual
traditions. Even though the question refers to the present time, the patient may re-
spond in terms of past affiliations or even aspirational ones. If the patient describes a
change in affiliations over time, use of the Spirituality, Religion, and Moral Traditions
supplementary module may be advised because these changes and the reasons for
them can be important markers of identity development, community engagement,
and/or attempts at coping with a clinical problem. Question 24 asks the patient about
the significance of spiritual, religious, and moral traditions in everyday life as a way
of evaluating his or her level of identification with that tradition and its importance
as a support or even potentially a stressor. The extent to which one or more traditions
affect everyday life likely correlates with the level of the person’s identification and
its impact on cultural identity. Question 25 asks the patient whether family members
share his or her traditions. If the answer is more toward the affirmative, this may clar-
ify the cultural context that supports the patient’s identification with the tradition.
Also, the patient’s identification might be preliminarily assessed to be normative for
the patient as an outgrowth of the family’s traditions. If the answer is more toward
the negative, the clinician would need to understand how this came to be and how
much of a stressor this discrepancy with family norms might be for the patient. Ques-
tion 25 has a built-in follow-up question to ask for more details in either case.
Video 11 delves into the interconnectedness of spirituality, religion, and moral tra-
ditions with cultural identity.
Video Illustration 11: You still show up on Sunday (3:26)
This video illustrates the use of the cultural identity questions (8–10) from the
core CFI. The patient’s answers reveal important values as well as conflicts
about his sense of himself that stem from the role of spirituality and religion in
his life. While attending church and Sunday school is a central aspect of his
background, and a source of his value system, he also indicates learning to
“put up a front.” He says this behavior was influenced by his mother, who had
“multiple nervous breakdowns” and “wouldn’t leave her bed” during the
week but would take pains to appear well enough in church on Sunday despite
being severely impaired at home. Not only does this comment provide impor-
tant family psychiatric history, but it also suggests an early conflict in the pa-
tient’s social development, in the sense of endorsing versus behaving
consistently with one’s values.
In response to the next question of the core CFI, on aspects of cultural identity
that make a difference to his anxiety, the patient describes the challenges of rec-
onciling his faith with his studies in cognitive science and his need for treat-
ment. On the one hand, the patient suggests that his anxiety, as “part of God’s
creation,” has value and is “beautiful in that way”; on the other hand, he also
says that he does not wish, or even need, to suffer as his mother did, suggesting
that she avoided treatment in part because of her religious values. While ac-
knowledging his need for anxiety treatment, he also states his preference to not
take medications, a preference guided by his religious values. The video con-
cludes with the third and final core CFI question on cultural identity, inquiring
whether aspects of his background or identity cause these concerns or difficul-
ties. The patient responds that living in New York challenges him to keep liv-
ing up to his religious values, suggesting that this tension contributes to his
anxiety symptoms.
Additional probes could elicit more information on these conflicts related to
the patient’s faith. Questions from the Spirituality, Religion, and Moral Tradi-
tions supplementary module might be helpful in this regard. For example, it
would be useful to know more about the patient’s specific faith tradition and
moral values, including the role of the religious community in faith members’
lives and their attitudes about mental health services. It could be useful to
treatment planning to explore the potential role of religious practices such as
reading or studying religious materials or prayer and the patient’s past expe-
rience of the usefulness of these practices for coping with his anxiety symp-
toms. Finally, in response to the last question of the video, exploring specific
“temptations” faced by the patient could identify stressors, conflicts, and cop-
ing strategies in relation to his anxiety symptoms and whether he has found a
church in New York that can expand his social network in a supportive way.
Relationship to Gender Identity and

Sexual Orientation Identity
One specific aspect of the impact of spirituality, religion, and moral traditions bears
mentioning. Conflicts may arise between the patient’s spiritual, religious, or moral
identity in the context of his or her sexual orientation and gender identities. These lat-
ter aspects of identity are explored in Cultural Identity supplementary module ques-
tions 26–32, discussed next in this chapter. They may be particularly important in
clarifying how the patient negotiates his or her sexual orientation and gender identity
in the context of his or her religious, spiritual, or moral life. For example, although
many Western mainstream religions may discourage, forbid, or even oppress homo-
sexuality, several studies suggest that gay and lesbian individuals can identify them-
selves as having rich spiritual and religious lives (García et al. 2008; Tan 2005). In
García et al.’s (2008) study, gay, bisexual, and transgender men described reconciling
their religious faith and their sexuality to some degree, whether they remained Cath-
olic, converted to another faith, or did not identify any formal religious or spiritual
affiliations. Many who did not identify with a particular group described continuing
to believe in God, pray, and read books on spiritual development. Although this
study included transgender individuals, few if any studies explore religious or spiri-
tual identity specifically in transgender populations. HIV infection can exacerbate the
sense of alienation from the church, and in Miller’s (2005) sample of interviewees
with AIDS, many left their religious institutions as a result. Seegers (2007) noted that
the gay men infected with HIV in her study endorsed an active and valued spiritual
life and religious practices and expressed their spirituality through practices at
Cultural Identity Related to Spirituality, Religion, and Moral Traditions 121
church; however, none had openly revealed their homosexuality or shared their HIV
status with their clergy or church community.
Conclusion
Because the impact of spiritual, religious, and moral traditions on a person’s life is im-
portant to explore among people presenting with psychiatric difficulties, these issues
are included as topics of assessment in the core CFI, in a separate supplementary
module, and as part of the Cultural Identity module. Here we focused on how clini-
cians should assess this domain through the Cultural Identity module.
KEY CLINICAL POINT

• Religious faith, spiritual affiliations, and/or moral commitments constitute important
components of a person’s cultural identity that can be explored with the Cultural
Formulation Interview as part of a cultural assessment focusing on the person’s ill-
ness interpretations and coping and help-seeking options.
Questions
1. How does a clinician assess the religious, spiritual, and moral components of
a person’s cultural identity?
2. In what ways do spiritual, religious, and moral traditions influence decisions

about health care and other forms of help seeking?
3. In what ways might a person's engagement with spiritual, religious, or moral

traditions contribute to increased emotional distress?
References
García DI, Gray-Stanley J, Ramirez-Valles J: “The priest obviously doesn’t know that I’m gay”:
the religious and spiritual journeys of Latino gay men. J Homosex 55(3):411–436, 2008
19042279
Miller RL Jr: An appointment with God: AIDS, place, and spirituality. J Sex Res 42(1):35–45,
2005 15795803
Peteet JR: Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment.
Washington, DC, American Psychiatric Publishing, 2004a
Peteet JR: Therapeutic implications of worldview, in Handbook of Spirituality and Worldview
in Clinical Practice. Edited by Josephson AM, Peteet JR. Washington, DC, American Psy-
chiatric Publishing, 2004b pp. 47–59
Seegers DL: Spiritual and religious experiences of gay men with HIV illness. J Assoc Nurses
AIDS Care 18(3):5–12, 2007 17570295
Shafranke EP: Religion and mental health in early life, in Religion and Mental Health. Edited
by Schumaker JF. New York, Oxford University Press, 1992
Tan PP: The importance of spirituality among gay and lesbian individuals. J Homosex
49(2):135–144, 2005 16048898
Suggested Readings
Anandarajah G, Hight E: Spirituality and medical practice: using the HOPE questions as a prac-
tical tool for spiritual assessment. Am Fam Physician 63(1):81–89, 2001 11195773
George Washington Institute for Spirituality and Health: http://smhs.gwu.edu/gwish/
Koenig HG: Spirituality in Patient Care: Why, How, When and What, 3rd Edition. Philadelphia,
PA, Templeton Foundation Press, 2013
Maugans TA: The SPIRITual history. Arch Fam Med 5(1):11–16, 1996 8542049
to Gender Identity and
Sexual orientation and gender identity form important aspects of cul-

tural diversity for lesbian, gay, bisexual, and transgender (LGBT) individuals. Unfor-
tunately, until recently, the cultural relevance of these identities was obscured from
mainstream mental health practice, or sexual orientation and gender identities were
treated with censure and moral disapprobation, as evidenced by the inclusion of sex-
ual orientation as a mental illness in DSM until 1973. In recent decades, however,
LGBT individuals have made rapid social progress toward recognition and respect
from mainstream institutions, including psychiatric ones. Recent evidence suggests
that LGBT individuals are more likely than heterosexuals to seek mental health treat-
ment (Cochran et al. 2003). Consequently, it is essential that mental health profession-
als are competent in assessing and treating individuals with diverse sexual
orientations and gender identities.
The Cultural Formulation Interview (CFI), including the supplementary modules,
advances clinicians’ cultural competence by providing straightforward prompts for
assessing the relevance of a patient’s sexual orientation and/or gender identity to the
mental health concerns presented by the patient. Here we review empirical research
on five domains that are most relevant to the assessment of the impact of sexual and
gender identity on mental health to provide guidance to clinicians on how to assess
these clinically meaningful areas. We first discuss the assessment of sexual and gen-
der identity as outlined in the Cultural Identity supplementary module (provided in
Appendix C of this handbook), followed by brief summaries of the importance of
these aspects of identity for all the domains assessed in the core CFI and further elab-
orated in the supplementary modules.
Gender and Sexual Orientation Identity

Gender refers to a socially constructed notion of masculinity or femininity that describes
the roles, behaviors, activities, or attributes that society considers appropriate for men
123
and women. Gender is not always aligned with biological sex and does not always de-
scribe a purely dichotomous phenomenon; that is, gender can be fluid. For transgender
individuals, gender identity does not conform to conventional, dichotomous notions of
male or female or the biological sex to which one was assigned at birth. Sexual orienta-
tion, in contrast, typically refers to the way in which an individual identifies his or her
sexual orientation in relation to the gender or sex to which he or she is attracted.
Although it can be argued that LGBT individuals belong to a distinct culture (Du-
berman et al. 2002), the meaning of that culture and any LGBT individual’s degree of
identification with it vary widely and likely will continue to change in the face of
rapid social progress and the greater possibility of assimilation into mainstream cul-
tures. Therefore, the CFI prompts providers to broadly assess all patients’ sexual ori-
entation and gender identities and the developmental trajectories of these identities.
The Cultural Identity supplementary module prompts mental health practitioners
to systematically assess these aspects of identity using matter-of-fact, open-ended
questions. By assessing all patients’ sexual orientation and gender identities, provid-
ers avoid making assumptions about those identities and their relevance to any given
patient. By asking, for example, “How would you describe your sexual orientation?”
(question 29) or “What label do you prefer for your gender identity?” clinicians pave
the way for open sharing of many possible identities. Clinicians can expect a variety
of responses to these questions, especially among younger generations of sexual and
gender minority individuals (e.g., those who identify as LGBT, who engage in same-
sex sexual behavior, who are gender nonconforming, or who otherwise do not identify
their sexual orientation as heterosexual or their gender identity in binary terms), who
are especially likely to identify their sexual orientations and gender identities using a
range of options (e.g., queer, pansexual) rather than more traditional labels (e.g., les-
bian, transgender) (Pantalone et al. 2014). Clinicians should use the term(s) that the
client prefers and explore the meaning of these terms for the individual. Furthermore,
clinicians should avoid assuming binary gender conceptualizations (i.e., male and fe-
male), because some patients identify themselves and their partners in nonbinary
terms. Therefore, rather than asking, “Do you have sex with men, women, or both?”
clinicians can pose more open-ended prompts, such as “Tell me about your recent sex-
ual partners,” to capture the full range of genders with which patients and their part-
ners might identify.
LGBT individuals do not uniformly follow a single trajectory of identity-related
development (Floyd and Bakeman 2006). However, certain aspects of sexual and gen-
der identity development are common and therefore warrant consideration when
conducting the CFI. Although many LGBT people become aware of their sexual or
gender identity early in life—even in childhood—sexual and gender identity mile-
stones can occur at any point in the life course. For sexual minority individuals,
awareness of a nonheterosexual identity typically precedes self-identification as les-
bian, gay, or bisexual, which typically precedes one’s first same-sex sexual encounter.
The first same-sex sexual encounter, in turn, typically precedes initial disclosure of
one’s sexual identity to another person (Calzo et al. 2011). Similarly, for transgender
individuals, awareness typically precedes disclosure, which precedes considerations
of transitioning gender identities, which may or may not be sought (Bockting and
Gender Identity and Sexual Orientation Identity 125
Coleman 2007). However, because this sequence of identity-related milestones is not

guaranteed across LGBT people, nuanced assessment is necessary. The attainment
and sequence of these milestones represent important determinants of LGBT individ-
uals’ mental health. For example, early achievement of identity-related milestones
may expose some LGBT people to greater lifetime victimization, such as from peers
at school (Kosciw et al. 2010); conversely, later achievement of milestones, such as
first disclosure, can lead to mental health challenges associated with exiting hetero-
sexual life or prolonged exposure to living and publicly identifying as one gender be-
fore transitioning to another. Providers ought to be aware of age cohort influences on
these milestone effects, because older cohorts may have attained identity-related
milestones at a later age because of the greater stigma toward LGBT people in more
distant decades than at present. Furthermore, compared to young LGBT individuals,
older LGBT individuals who attained these milestones at an earlier age may have
been subjected to more stigma and thus more threats to mental health (D’Augelli
2002). Supplemental prompts to the CFI for assessing identity-related milestones
might include “When did you first know that you were [gender identity or sexual ori-
entation]?” and “Tell me about your early sexual experiences.”
Unlike some cultural identities, sexual orientation and gender identity are rela-
tively concealable. After a period of initial awareness of one’s sexual or gender iden-
tity, most LGBT individuals choose to disclose their sexual orientation or gender
identity to others. When, how, and to whom LGBT individuals disclose depend on
personal and situational contexts and can be both voluntary and involuntary. Disclos-
ing one’s sexual or gender identity—a process known as coming out—represents an im-
portant, and sometimes ongoing, task for most LGBT individuals and one that can
have important implications for mental health. Coming out alleviates the mental bur-
den of concealment (Pachankis 2007) but also invites the stress of navigating a new
public identity (JE Pachankis, SD Cochran, VM Mays, “Mental health correlates of
concealment and disclosure among sexual minority adults: a population-based
study,” Yale School of Public Health, Yale University, New Haven, Connecticut, 2014).
Disclosure can usher in a period of exploration of LGBT communities, friendships, and
romantic and sexual partners. LGBT individuals vary widely in their degree of affilia-
tion with LGBT communities, and such affiliations can be associated with both risk
and resilience (Lelutiu-Weinberger et al. 2013). Therefore, understanding a patient’s
experience of disclosure and concealment, as well as the factors motivating continued
concealment, can help direct culturally sensitive case formulation. Recommended
questions to facilitate an exploration of developmental experiences include these:
“Whom have you told about your sexual orientation or gender identity? How did they
react? Whom have you not told? How connected do you feel to an LGBT community?”
Conceptualizations of Distress
Among LGBT Patients
The Cultural Identity module instructs providers to assess the relevance of gender
identity and sexual orientation identity to LGBT patients’ distress by asking, “Do you
feel that your [gender identity or sexual orientation] has influenced your [PROBLEM]
or your health more generally?” (questions 26 and 30). In asking this question, pro-
viders should be familiar with the vast amount of research suggesting that LGBT in-
dividuals experience more mental (Hatzenbuehler 2009; Meyer 2003) and physical
(Lick et al. 2013) health problems than heterosexual individuals. Sexual minority in-
dividuals are disproportionately likely to experience mood, anxiety, and substance
use disorders compared to heterosexuals (Cochran et al. 2003). Preliminary evidence
also suggests that transgender individuals experience numerous mental health and
psychosocial burdens, including high rates of incarceration, homelessness, and un-
employment (Herbst et al. 2008). LGBT individuals are also disproportionately at risk
for suicide ideation and attempts (Eisenberg and Resnick 2006). The preponderance
of evidence suggests that these sexual and gender identity disparities in mental
health and psychosocial risk are a function of stigma-related stress (i.e., the stress re-
sulting from LGBT individuals’ disadvantaged social status) (e.g., Meyer 2003).
In addition to being at disproportionate risk for experiencing these mental health
problems compared to the general population, LGBT individuals are significantly
more likely to meet criteria for more than one psychiatric disorder, including com-
bined mental health and substance abuse disorders (Cochran et al. 2003). Providers
ought to consider the possible impact of comorbidity on symptom presentation of
LGBT patients and the severity of their distress and functional impairment. Comor-
bidity can complicate both diagnosis and treatment. Additionally, some evidence
suggests that mental health problems arise earlier among LGBT individuals than in
the general population (Gilman et al. 2001). Therefore, compared to other patients,
LGBT patients might present for treatment at an earlier age or with more severe im-
pairment after a potentially prolonged symptom course.
Mental health providers should carefully consider that although epidemiological
evidence shows that social stigma affects mental illness etiology, presentation of
symptoms, and course among LGBT individuals, LGBT patients themselves might
not readily perceive the adverse impact of stigma on their mental health. Throughout
history, narratives of LGBT identity often emphasized the burden of stigma-related
stress, although more recent narratives of LGBT identity also emphasize the resilience
and creativity displayed by sexual and gender minority individuals (Cohler and
Hammack 2007). Therefore, providers ought to consider these narrative influences on
their patients’ responses to the identity-impact prompt in the CFI. Upon asking the
query “Do you feel that your [gender identity or sexual orientation] has influenced
your [PROBLEM] or your health more generally?” providers should also be aware
that the influence of identity-related stress on LGBT individuals’ health is often insid-
ious and invisible.
Psychosocial Stressors and Cultural Features

of Vulnerability in LGBT Patients
As mentioned in the section “Conceptualizations of Distress Among LGBT Patients,”
research convincingly links the substantial mental health disparities due to gender
and sexual identity to LGBT individuals’ disproportionate exposure to stigma-related

stress. Therefore, providers should familiarize themselves with the specific forms of
stress experienced by LGBT individuals, because these stressors can impact symp-
tom presentation, inform treatment planning, and complicate diagnosis. These
stressors include stigmatizing social contexts, which operate through concealment,
expectations of rejection, internalized homophobia, and elevations in general vulner-
ability factors to heighten the risk for psychiatric disorder among LGBT individuals
(Hatzenbuehler 2009; Meyer 2003).
Stigmatizing social contexts can include parents, peers, religious communities,
school environments, and workplaces that perpetuate stereotypes, generate distance,
and deny LGBT individuals the same rights and opportunities afforded heterosexual
and cisgender individuals (i.e., individuals whose gender identity matches their as-
signed sex at birth) (Meyer 2003). LGBT youth experience significantly more parental
and peer rejection than heterosexual youth (Balsam et al. 2005). For LGBT individu-
als, parental rejection is associated with adverse mental health outcomes (Ryan et al.
2009), whereas parental support is protective against the development of mental
health problems (e.g., Goldfried and Goldfried 2001). Similarly, religious communi-
ties, schools, and workplaces can serve as sources of either stress or support depend-
ing on the degree of acceptance they communicate toward LGBT individuals (e.g.,
Russell et al. 2009). Furthermore, laws and policies that deny LGBT individuals the
same rights as heterosexuals, as well as community-level attitudes that communicate
mistrust or dislike of an LGBT identity, are associated with elevated risk for psychiat-
ric disorders and suicide attempts among LGBT individuals (e.g., Hatzenbuehler
2011; Hatzenbuehler et al. 2010). Therefore, clinicians should assess the degree of
LGBT-related stigma or support in the current and past contexts in which LGBT pa-
tients live. Provider assessments of social-contextual factors surrounding LGBT pa-
tients might include the following, for example: “How supportive are your parents,
school, and religious community of your sexual orientation?” “In what situations do
you feel most comfortable being LGBT?”
An LGBT identity for some individuals is central and salient to their overall iden-
tity, whereas an LGBT identity is secondary for others. The influence of stigmatizing
contexts on LGBT individuals’ mental health likewise varies as a function of LGBT
identity centrality and salience. A central and salient LGBT identity is more likely
than a less central and salient identity to be associated with distress in stigmatizing
social contexts (Quinn and Chaudoir 2009). Thus, in addition to the contextual assess-
ment described in the previous paragraphs, providers ought to consider assessing the
interaction of contexts with identity centrality and salience. For example, the core CFI
suggests the question “For you, what are the most important aspects of your back-
ground or identity?” (question 8), which can be supplemented with questions such as
“How important is your sexual orientation or gender identity to you?”
Stigma operates through several stress mechanisms to elevate risk for psychiatric
disorders (Hatzenbuehler 2009). LGBT-specific stress mechanisms through which
stigma impairs mental health include concealment, chronic expectations of rejection,
and internalized stigma (Meyer 2003). Although many LGBT individuals may have
disclosed their gender identity or sexual orientation to many people in many situa-
tions, coming out is an ongoing process, because new situations have to be assessed
for safety and a decision has to be made regarding the benefits versus costs of disclo-
sure in each new context. LGBT individuals who choose to conceal their sexual or
gender identity may experience well-documented cognitive, affective, and interper-
sonal strains that elevate the risk for mood, anxiety, and substance use disorders
(Pachankis 2007). LGBT individuals who experience early or ongoing rejection di-
rected toward their sexual or gender identity might be particularly likely to expect
ongoing rejection, especially in ambiguous situations (Pachankis et al. 2008), which
can also elevate risk for psychiatric disorder (Feinstein et al. 2012). Finally, LGBT in-
dividuals who live in stigmatizing locales or experience more frequent prejudice and
discrimination are more likely to direct stigmatizing attitudes toward themselves
(Berg et al. 2013), with adverse implications for mental health (Newcomb and Mus-
tanski 2010).
Evidence also suggests that because of their disproportionate exposure to stigma-
related stressors, LGBT individuals have elevations compared to the general
population in general psychiatric vulnerability factors, including emotion regulation
difficulties, negative cognitive biases, and interpersonal problems. Elevations in these
processes can begin early for LGBT individuals (Hatzenbuehler 2009). In addition to
assessing stigma-related stressors and mechanisms, mental health providers should
also closely assess elevations in general vulnerability factors among LGBT patients,
even when full diagnostic criteria for psychiatric disorders are absent.
Psychiatric diagnosis of LGBT individuals is often complicated by the fact that
some symptoms of psychiatric disorders represent functional adaptations to stigma
rather than forms of psychopathology. For example, social anxiety and concomitant
fears of negative evaluation are common among individuals who possess a conceal-
able stigma (Pachankis 2007). Social anxiety disorder would be an inappropriate di-
agnosis among LGBT individuals whose fears of rejection or negative evaluation are
grounded in accurate expectations of rejection or negative evaluation in LGBT-hostile
social climates. Similarly, identity confusion is built into developmental models of
LGBT identity formation (e.g., Cass 1984) and is normative in social contexts that stig-
matize LGBT identities. Fears of disease are normative among gay and bisexual men
(Odets 1995) given the very high rates of HIV infection in the gay and transgender
communities. Finally, substance use norms are more permissive within LGBT com-
munities, which at least partially explains LGBT individuals’ greater use of sub-
stances compared to the general population (Cochran et al. 2012; Green and Feinstein
2012). These cultural features of distress influence diagnostic decision making and
therefore underscore the paramount importance of assessing the relevance of LGBT
stigma to psychiatric symptoms. This assessment can be complemented by a review
of LGBT patients’ own attributions for their distress as well as the developmental and
contextual influences discussed above. The CFI can help providers formulate the rel-
evance of LGBT stigma to diagnosis and includes questions such as “Why do you
think this is happening to you? What do you think are the causes of your [PROB-
LEM]?” (core CFI question 4) and “Do you feel that your [gender identity or sexual
orientation] has influenced your [PROBLEM] or your health more generally?” (Cul-
tural Identity module questions 26 and 30). Asking these questions can help provid-
ers recognize cultural features of vulnerability among LGBT patients in order to make
culturally informed diagnoses.
Video 12 deals with anger and impulsive behavior issues that stem from sexual
orientation identification.
Video Illustration 12: Ties that bind (3:35)
In this video, the clinician illustrates the use of the core CFI with a young Pak-
istani woman who is being evaluated in the emergency department for anger
issues and impulsive behavior in the context of a tumultuous relationship with
her family, exacerbated by her parents’ discovery that she has been involved in
a romantic relationship with another woman. In response to the clinician’s gen-
eral prompts about the nature of the problem, the patient describes her social
isolation and feelings of not fitting in at home or school as causing her to adopt
an angry, defensive stance. Hewing closely to the CFI, the provider then asks
the patient to describe the most important aspects of her identity among sev-
eral options, including gender and sexual identity. In response, the patient de-
scribes the strict, religious household in which she was raised. She then
confides that her present problems stem from her family’s discovery of her ro-
mantic relationship with another woman, which led her family to view the pa-
tient as a disappointment and to contact the other woman’s family to discuss
the situation. The provider then continues using the CFI to explore how the pa-
tient’s background shapes her coping skills and help-seeking needs. The pa-
tient focuses her answers to these questions on her strict upbringing.
The provider’s use of the CFI yields a strong picture of the patient’s cultural
background. The provider’s open questioning regarding important aspects of
identity likely paved the road for the patient to disclose her recent romantic re-
lationship with a woman and the ensuing stress caused by her parents’ discov-
ery of this relationship. The supplementary guidance provided in this chapter
suggests further areas of questioning to specifically ascertain the relevant fea-
tures of the patient’s sexual orientation. Given that many patients might have
difficulty discussing their gender or sexual identity and given the sometimes
invisible impact of these identities on mental health, we suggest that providers
ask several specific follow-up questions beyond the core CFI to capture these
aspects of identity. For instance, in this assessment, the provider might have
gained a deeper understanding of the patient’s sexual identity had he asked
how she describes her sexual identity (e.g., lesbian, bisexual, queer), about the
importance she ascribes to this identity, and when she first became aware of
this identity. By pointedly asking, “Do you feel that your sexual orientation has
influenced your current problems or your health more generally?” the pro-
vider might have gained insight into how the patient conceptualizes her cur-
rent distress in light of her sexual orientation and the stress it poses to her
family relationship. Given this patient’s strained relationship with her family,
it would also be important to assess her other sources of support, including
from friends, romantic or sexual partners, and the LGBT community. Assess-
ing the resilience that she has displayed in establishing a minority sexual iden-
tity might have introduced a relatively positive perspective on this presently
stressful situation.
Cultural Features of Coping and Help Seeking

Among LGBT Patients
The CFI instructs providers to assess factors related to coping and help seeking. Spe-
cifically, the core CFI suggests that providers ask, “Sometimes people have various
ways of dealing with problems like [PROBLEM]. What have you done on your own
to cope with your [PROBLEM]?” (question 11) and “Often, people look for help from
many different sources, including different kinds of doctors, helpers, or healers. In the
past, what kinds of treatment, help, advice, or healing have you sought for your
[PROBLEM]?” (question 12). LGBT individuals are significantly more likely to seek
help for mental health problems than the general population (Cochran et al. 2003).
This greater treatment seeking may be a result of the significant mental and physical
health disparities that exist for sexual orientation and gender identity or a function of
the self-exploration and personal growth that might be embedded within LGBT com-
munities because of the LGBT identity development process (Balsam et al. 2006). This
greater use of treatment among LGBT individuals compared to the general popula-
tion is all the more striking given the structural barriers (e.g., fewer financial re-
sources, greater lack of health insurance) and history of ineffective and unethical
mental health treatments (e.g., sexual orientation conversion therapy) faced by this
population (Cochran 2001). To facilitate an understanding of the treatment-seeking
barriers that LGBT patients may face, the Cultural Identity module instructs provid-
ers to ask, “Do you feel that your [gender identity or sexual orientation] influences
your ability to get the kind of health care you need for your [PROBLEM]?” (questions
27 and 31).
In addition to their higher use of professional mental health services, LGBT individ-
uals may be more likely to seek and receive social support from families of choice than
from families of origin (Oswald 2002), given that they often do not share the same sex-
ual or gender identity as their parents and often experience rejection from families. Re-
latedly, social networks may be more fluid among LGBT individuals, who may
embrace the opportunity to redefine traditional connections and relationships to create
a support network. For example, LGBT individuals’ social networks might be more
likely to include former romantic or sexual partners than might be usual for heterosex-
ual or cisgender individuals. Additionally, LGBT role models are an important source
of resilience and support for LGBT individuals (Bird et al. 2012), but role models are
also not easily accessible in all contexts, especially for young LGBT individuals, for
whom a generation of potential role models was decimated by the early HIV/AIDS ep-
idemic and because of stereotypes surrounding bonds between older and younger
LGBT individuals (Bird et al. 2012). Finally, the coming-out process, given its potential
challenges, provides LGBT individuals a mastery experience that can be drawn on to
overcome subsequent challenges. In addition to asking the standard core CFI questions
about coping and help seeking, providers can ask additional questions to assess the
coping and social support resources available to their LGBT patients, such as “What
role do your friends and partners play in your life? Who are your role models? What
strengths do you possess because of your gender identity [or sexual orientation]?”
Cultural Features of the Relationship Between

LGBT Individuals and Clinicians
Given that gender identity and sexual orientation represent important components of
cultural identity for many LGBT individuals, providers ought to become familiar
with LGBT cultures and apply models of multicultural competence to the treatment
of LGBT patients (e.g., Pachankis 2014; Pachankis and Goldfried 2004). To this end,
providers should familiarize themselves with the unique issues and social norms
among this group. For example, the term homosexual has pathological and medicaliz-
ing undertones given its historical usage. The term fails to describe individuals who
possess bisexual identities as well as lesbian and gay men who identity as lesbian or
gay without engaging in same-sex sexual behavior. Furthermore, different cultures
and societies use terms other than lesbian, gay, bisexual, or transgender to refer to their
sexual and gender minority populations. Providers should become familiar with
these terms as well as the intersection of sexual orientation and gender identity with
other forms of cultural diversity (e.g., race, ethnicity, nationality). Additionally, given
that there is no single LGBT culture, providers should become familiar with the het-
erogeneity within the various LGBT cultures and assess the nature of the LGBT cul-
tures with which their patients identify.
The CFI suggests assessing patient concerns about provider discrimination and
cultural misunderstanding because such concerns act as barriers to receiving help.
Specifically, the Cultural Identity module suggests asking, “Do you feel that health
care providers have certain assumptions or attitudes about you or your [PROBLEM]
that are related to your [gender identity or sexual orientation]?” (questions 28 and 32).
In fact, LGBT individuals may experience shame and embarrassment about disclos-
ing relatively normative features of LGBT life that may be nonnormative among het-
erosexuals. For example, relationship arrangements for same-sex partners are often
more flexible and open than they are in heterosexual relationships (e.g., multiple part-
ners concurrently; Parsons et al. 2013). Some bisexual individuals are married to an
opposite-sex partner and therefore may have difficulty finding support for their bi-
sexual identity. Furthermore, some transgender individuals may seek mental health
services related to the gender transition process and therefore require that their pro-
vider possess sufficient understanding of that process (Bockting et al. 2006). Without
direct examination of patients’ potential expectations of provider bias and the pro-
vider’s explicit demonstration of LGBT cultural competence, these features of some
LGBT patients’ lives might remain undisclosed, despite potential relevance to the is-
sues presented by patients.
Although providers should assess the relevance of LGBT patients’ sexual and gender
identity to the presented problem, providers should also be careful not to overemphasize
sexual orientation or gender identity, especially when these identities are irrelevant to the
patient’s presented problem. Some patients’ problems will be closely related to their ex-
perience of being LGBT (e.g., fear of coming out to others); for other patients, however,
sexual orientation and gender identity may form part of the general background but not
be directly related to the presented problem (e.g., general social isolation, including from
LGBT peers) (Safren and Rogers 2001). The CFI directs providers to assess the relevance
of this feature of cultural diversity to ensure optimal service delivery.
Conclusion
The CFI provides straightforward guidance for assessing the relevance of patients’
sexual orientation and gender identities to the mental health concerns presented. The
CFI supplementary modules regarding psychosocial stressors, identities, and coping
and help-seeking tendencies will likely be particularly relevant for assessing the cul-
tural context of LGBT patients’ current mental status. Assessment of sexual orienta-
tion and gender identities, the mental health concerns particularly relevant to LGBT
patients, the cultural conceptualizations of distress and coping among LGBT individ-
uals, and the relevance of LGBT identities to the provider-patient relationship should
form a core part of culturally competent psychiatric care. The questions contained in
the core CFI and the supplementary modules can assist providers in conducting such
an assessment.
KEY CLINICAL POINTS

• A patient’s gender and sexual identities can affect his or her conceptualizations of
distress, generate insidious psychosocial stressors, and yield distinct forms of cop-
ing and help seeking, all of which form essential components of a culturally sensi-
tive case formulation.
• Because gender and sexual identities occur in a distinct and changing social con-
text characterized by both stigma and social progress, systematically eliciting the
meaning and experience of gender and sexual identity for each patient against a
backdrop of familiarity with LGBT culture will yield an LGBT-sensitive case formu-
lation.
Questions
1. What features of LGBT identities are relevant to a culturally sensitive case for-
mulation?
2. How do gender identity and sexual orientation identity affect distress for
LGBT clients?
3. How does LGBT stigma complicate psychiatric diagnosis?

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Coping and Help Seeking
The DSM-5 (American Psychiatric Association 2013) Cultural Formulation

Interview (CFI) is a powerful clinical tool for assessing cultural factors using a per-
son-centered approach. Two areas critical to a person-centered assessment are coping
and help seeking. Coping refers to the techniques an individual employs to redress a
problem, whereas help seeking refers to the specific ways the person seeks assistance
for the problem from others (Hwang et al. 2008). Coping can target emotional and/or
somatic aspects of distress. For example, a veteran of the Iraq War may use prayer to
relieve combat-related distress, focusing on the psychological aspects of anxiety and
guilt, whereas a Cambodian refugee may use “coining” to relieve panic symptoms,
focusing on the somatic aspects of anxiety. (In coining, a coin dipped in a camphor-
containing substance such as tiger balm is rubbed vigorously against the body to pro-
vide a path for the “bad wind” to be released from the body [Hinton et al. 2010].)
Help-seeking behavior is often classified into two general types: formal and informal.
Formal help seeking involves assistance from clinicians (e.g., psychologists) who are
regulated by government agencies, whereas informal help seeking recruits the support
of individuals not scrutinized by government officials (e.g., nontraditional healers,
priests, friends) (Hwang et al. 2008). Questions about both formal and informal help
seeking are included in the CFI assessment.
The core CFI prioritizes the assessment of coping and help seeking, featuring
them prominently in two domains: 1) “Cultural Factors Affecting Self-Coping and
Past Help Seeking” and 2) “Cultural Factors Affecting Current Help Seeking.” In ad-
dition, clinicians may choose to further investigate these areas using the supplemen-
tary module Coping and Help Seeking, which is the topic of this subchapter. We
briefly review the literature that underscores the importance of assessing coping and
help-seeking behavior, give a description of the supplementary module, and illus-
trate the module’s use with a case example that highlights the importance of obtain-
ing this information to maximize treatment efficacy and adherence.
136
Supplementary Module 7: Coping and Help Seeking 137
Why Assessing Coping and Help-Seeking

Behavior Is Important
Assessing coping and help seeking can provide useful information as to what the pa-
tient hopes for from the current treatment and what he or she wants to avoid. An ac-
count of past choices can reveal what the patient found to be more or less useful in
dealing with the problem. For example, the patient may have previously found psy-
chiatric treatment not to be helpful, and exploring past treatment experiences should
provide invaluable information, particularly when the clinician is a psychiatrist. In-
formation on the patient’s practices and help-seeking choices can also help the clini-
cian reconcile proposed therapeutic approaches with the patient’s expectations,
including potentially how to amplify the clinical therapies by pairing them in some
way with the patient’s own behavior. For example, coping techniques such as Bud-
dhist meditation or other forms of spiritual practice may be valuable healing mo-
dalities that can be encouraged and amplified in treatment, for instance, by
incorporating them into cognitive-behavioral therapy interventions (Hinton et al.
2012). To obtain more detail on spiritual practices, the clinician can administer the
Spirituality, Religion, and Moral Traditions supplementary module, which may be
useful in conjunction with the module Coping and Help Seeking because many cop-
ing and help-seeking behaviors involve spiritual traditions. The module Coping and
Help Seeking also explores the current presentation to treatment as the most recent
instance of help seeking. Useful information for engagement and treatment planning
can be obtained by determining who suggested that the patient present for care at this
time and what treatments the patient currently expects to receive. To increase positive
expectancy and adherence, treatment may be presented in terms of the patient’s cur-
rent means of self-coping.
Another reason why information about past coping and help seeking is valuable
to clinical care is that it constitutes a window into how the patient conceptualizes the
problem, including his or her explanatory model (or models) of the disorder. For ex-
ample, if a Latino patient has sought help for the problem from a Santeria priestess,
it is important to find out what problem the patient presented to the healer, how the
healer explained the problem, what treatments were suggested, and whether the pa-
tient found them helpful. The clinician would also like to know whether such treat-
ments are ongoing, because this may reveal the patient’s current views on the illness
and potentially the patient’s expectations about the treatment being sought from the
clinical provider.
Video 13 uncovers the patient’s coping mechanisms.
Video Illustration 13: I don’t have a problem (3:00)
The video entitled “I don’t have a problem” illustrates how a patient may em-
ploy various strategies to cope with her condition. Initially, the patient denies
any difficulties: “First of all, I don’t have a problem.... I think I’m fine.” As the
CFI interview proceeds, however, asking what is most troubling about her sit-
uation reveals some of her coping strategies, which include overeating and
oversleeping. These help her feel a little better but then exacerbate her depres-
sive symptoms—which the patient labels “a little down” or “moody”—and
also lead to distressing weight gain. In response to core CFI question 5, another
important coping strategy emerges. The patient speaks to her sister Rachel “ev-
ery day,” who knows “everything that is going on in my life.” Rachel believes
that the patient is depressed because “all of my friends are getting married”
and “I don’t have [a relationship] of my own.” Rachel also fears that the patient
has the same depressive illness that affected their aunt.
Talking with her sister is a help-seeking strategy in which the patient seeks as-
sistance from her social network. The Coping and Help Seeking supplemen-
tary module could help the clinician explore these issues further, particularly
the two social network items (questions 6 and 7). It would be beneficial to ex-
plore whether talking about “feeling down” with her sister helps her and in
what way. Given the patient’s reluctance about treatment, this material may be
particularly useful to engage her in therapy. This information can also help the
clinician reconcile the proposed therapeutic approaches with the patient’s ex-
pectations, including potentially how to amplify the clinical therapies by pair-
ing them in some way with the patient’s own behavior.
Overeating and oversleeping constitute other important coping strategies for the
patient. She feels ambivalent about these, because she dislikes the ensuing weight
gain; this could be an avenue for assessing their effectiveness as behaviors. The
Coping and Help Seeking supplementary module could be useful on this point,
particularly the five questions (1–5) on self-coping. Enhanced awareness of the
connection between eating and sleeping and feeling down may help her change
her eating and sleeping habits as treatment progresses and may also guide her
choices of alternative and more productive coping strategies. This kind of informa-
tion is crucial for a person-centered approach to care that takes into consideration
the meaning patients ascribe to symptoms and behaviors.
Video 14 addresses the patient’s perception of how to cope and what treatment
would best suit her.
Video Illustration 14: Planning for something better (1:59)
In the video “Planning for something better,” the core CFI questions (14–16) on
help seeking and the clinician-patient relationship allow the patient to discuss di-
rectly what her coping and treatment preferences are. She believes that if she had
a safe place to live and someone to talk to she would be doing better. Using the CFI,
the interviewer explores her expectations and perceived barriers to treatment, and
the patient explains that a female clinician could help her more effectively. At this
point, the supplementary module on coping and help seeking, particularly the
self-coping questions (1–5), might help further identify her resources and strengths
and refine an effective treatment plan according to her needs and goals.
Arthur Kleinman (1978) introduced the concept of explanatory models of illness

into psychiatry to emphasize that patients’ interpretation and actual experience of an
illness are embedded within specific social contexts. Individuals from different cul-
tural backgrounds tend to categorize, label, and interpret their experiences differ-
ently. Furthermore, the ways in which they make sense of their problems affect how
they cope with them and/or seek help from others (Hinton and Good 2009; Kleinman
1978, 1988; La Roche 2013). Patients’ cultural views influence the selection of specific
coping strategies and help-seeking behaviors. For example, those who believe their
problems are psychological tend to seek help from mental health professionals,
whereas those who believe their problems are somatic seek help from a primary care
physician (Hwang et al. 2006). Demonstrating such a somatization perspective, 69%
of Chinese Americans meeting screening criteria for depression in the waiting room
of a primary care clinic had previously sought help for the depression from outpatient
medical services, whereas only 3.5% had sought care from a mental health profes-
sional (Yeung et al. 2004). The CFI identifies patients’ coping and help-seeking
choices so that more effective and culturally consistent strategies can be designed to
respond to their goals and characteristics, thereby enhancing treatment efficacy and
adherence (La Roche 2013).
Informal healing services are popular in the United States generally (Eisenberg et
al. 1998), but racial or ethnic minority groups may be more likely to turn to indige-
nous or complementary treatments for physical and mental health care (Barnes et al.
2004; Koss-Chioino 2000). For many racial or ethnic minority group members, reli-
gion can be a frequent source of coping strategies (e.g., prayers) and of help-seeking
options, such as obtaining the assistance of priests or pastors (George et al. 2000). For
example, African Americans may engage in more religious coping to deal with adver-
sity than non-Latino white Americans (Conway 1985–1986). Similarly, many Latinos
endorse Christian beliefs and prayer as a means to cope with adversity (La Roche
2013). Many racial or ethnic minorities report greater satisfaction with their religious
coping efforts than whites and tend to feel that these efforts result in a greater per-
sonal connection with God (Myers and Hwang 2004).
Structural factors also influence patients away from the formal health care sector,
and these factors reveal key areas that need to be addressed to ensure entry into and
adherence to care. For example, the selection of formal or informal help may be re-
lated to economic barriers that are more prevalent among racial or ethnic minorities;
these barriers include lack of insurance, limited job flexibility, and lower socioeco-
nomic status (U.S. Department of Health and Human Services 2001). Lack of insur-
ance in particular is a key predictor of lower formal help-seeking behaviors among
racial or ethnic minorities (U.S. Department of Health and Human Services 2001). A
contextually sound evaluation approach needs to elicit this information, as included
in core CFI question 13.
In addition, accessing mental health services becomes even more difficult for many ra-
cial or ethnic minority groups because they tend to have negative attitudes toward mental
health services. For example, because of historical experiences with racism and discrimi-
nation, many African Americans fear the mental health system (Keating and Robertson
2004); they lack confidence in it and feel that they have been mistreated and discrimi-
nated against by providers and the system as a whole (Smedley et al. 2003; U.S. Depart-
ment of Health and Human Services 2001). Stigmatization can also limit access to
mental health services (U.S. Department of Health and Human Services 1999). Stigma
toward mental illnesses is a worldwide phenomenon and operates by motivating the
general public to reject, avoid, fear, and discriminate against those with mental illness
(Corrigan 2004). As a result, persons with mental illness become ashamed, conceal their
problems, and delay or avoid seeking help owing to fear of being stigmatized and nega-
tively labeled. Stigma may be more severe among some racial or ethnic minority commu-
nities and may have a more detrimental impact on help-seeking behavior, partly as a
result of lower health literacy (U.S. Department of Health and Human Services 1999).
In some Asian cultures, stigma may reflect badly on the patient but also may diminish the
economic and marriage value for that person as well as his or her family (Ng 1997).

The Coping and Help Seeking module has four sections and 13 questions (see Appen-
dix C in this handbook). The questions are linked to the presented problem, and the
first three sections emphasize the perceived helpfulness of self-coping and help seek-
ing, whereas the fourth section, which is on the current treatment episode, explores
treatment expectations rather than helpfulness.
Self-Coping
Questions 1–5 assess general self-coping. The first question examines the way in
which an individual is currently addressing his or her problem and the level of help-
fulness of this coping strategy. The second question broadens the question to similar
problems in the past rather than the present. The next three questions ask about spe-
cific coping strategies—including use of the Internet and other media, spiritual prac-
tices, natural remedies, and over-the-counter medications—and inquire about the
level of helpfulness of each.
Social Network
Questions 6 and 7 assess the patient’s perception of the social network’s ability to help
him or her cope with the problem (e.g., by providing moral or other types of support)
and the social network’s influence on the method of coping and help seeking (e.g., a
family member’s etiological views of the problem often lead to certain suggestions
about how to deal with it). Question 6 inquires whether the individual has informed
a family member about the problem, whether the family member was helpful, and
what suggestions were offered. Question 7 assesses the same topics with respect to a
coworker or friend instead of a family member.
Help- and Treatment-Seeking Beyond Social Network

Questions 8–11 ask about helpers beyond the usual social network. The module taps
the following sectors: spiritual, religious, and moral helpers; general doctors; mental
health providers; and any other healers (e.g., acupuncturists, chiropractors). The
questions inquire about the care received from each and its helpfulness.
Current Treatment Episode

The final two questions focus on the circumstances that led the individual to seek cur-
rent treatment. Question 12 investigates who suggested accessing care now and why
this type of treatment was suggested. Question 13 examines the patient’s treatment
expectations for the problem that brings him or her into care.
Clinical Use of the Module

The following case illustrates the clinical value of information about a patient’s cop-
ing and help seeking. In this case, the information elicited by the supplementary
module helped to prevent the patient from discontinuing treatment prematurely, as
she had done in the past with a different provider, and helped in the selection of in-
terventions that matched her treatment goals. The relevant sections of the module are
noted in parentheses and italics.
Case Vignette
Elena, a 55-year-old woman from the Dominican Republic, is an unemployed mother of
three and grandmother of eight who sought psychotherapy for the first time because of
severe symptoms of anxiety, particularly insomnia (presented problem on the core CFI). She
explained that the spirit of her recently deceased mother was visiting her at night. When
asked how she coped with these visits, Elena reported “ignoring them” (self-coping). Un-
fortunately, this was not useful; her insomnia continued. Thus, she consulted with a
friend (social network), who advised her to talk with her priest (help and treatment seeking
beyond social network) because the patient is a devout Catholic. The priest encouraged her
to pray a “Hail Mary” and an “Our Father” (self-coping) before going to bed. Although
praying was somewhat helpful, she still had difficulties falling asleep. In further discuss-
ing her difficulties with her cousin (social network), Elena was encouraged to seek mental
health help. At the first mental health clinic she attended, she met with a “tall, white,
American psychiatrist” (help and treatment seeking beyond social network), who explained in
English that spirits do not exist and that she should take medications to cope with her
fears and high anxiety levels. She felt misunderstood and never returned to this psychia-
trist or considered taking medications. Subsequently, Elena tried another mental health
clinic with a Latino-focused program (current treatment episode). She reported liking this
psychologist, who was Latino and communicated with her in Spanish. During this eval-
uation, she was able to talk about her fear of the spirit visitations. Unlike with the psychi-
atrist, she felt understood and accepted by the psychologist; she felt that her goals were
being met, which allowed her to be open and engaged in the psychotherapeutic process.
Elena remained in treatment for eight sessions. Over time, her initial complaint of in-
somnia and spirit involvement evolved into a description of her feelings of guilt for having
“abandoned” her mother in Santo Domingo to come to the United States. With the help of
her psychologist, she was able to reframe her migration as a necessary and adaptive solu-
tion to the problem of being left by her husband in the Dominican Republic with three chil-
dren and no economic support (current treatment episode). The psychologist’s reframing
coincided with that of Elena’s priest, who also explained that she had not sinned in leaving
her mother but instead had tried to do her best under extremely adverse circumstances (help
and treatment seeking beyond social network). The patient, however, continued to feel guilty
and depressed, especially when she missed her mother. Her priest recommended that she
pray for her mother’s soul every night (help and treatment seeking beyond social network), a
suggestion that her psychologist heartily endorsed. The patient started to feel very close to
her mother during her prayers and soon started praying in other circumstances when she
was anxious or depressed (self-coping). As her symptoms began to lift, Elena explained this
as a sign that God was giving her strength to cope with her problems.
Conclusion
We have highlighted the importance of systematically identifying and understanding
a patient’s coping and help-seeking behaviors and have shown how to use the CFI
Coping and Help Seeking module to achieve this. The ways a patient has sought help
in the past for a problem reveals key information about how the patient conceptual-
izes the problem and about previous treatment failures, stigmatization, access to
treatment, and expectations about current care. This information is invaluable clini-
cally, giving insight into how to overcome treatment barriers and increase adherence,
cultural consonance of treatment, efficacy, and therapeutic alliance.
We also indicate future areas of research. First, self-coping narratives may reveal
key local sources of resilience (Hinton and Kirmayer 2013; La Roche 2013), such as
prayer or meditation. Both of these are consonant with current cognitive-behavioral
therapy theory and can be integrated into care in order to increase efficacy and cul-
tural acceptability of treatment, as well as treatment adherence, as illustrated in the
case vignette (Hinton et al. 2012; La Roche 2013). Second, self-coping and help seeking
represent key areas for research on treatment dissemination and implementation
more generally, particularly in low-resource settings where shifting to less expensive
helpers is a priority (Jordans and Tol 2013). A person’s self-coping and help seeking
reveal how problems are locally managed outside the formal health care system,
which yields useful information about how to increase utilization and efficacy of, as
well as adherence to, psychological and biomedical treatment.
Assessing coping and help seeking provides insight into the patient’s conceptual-
ization of his or her problem, previous treatment failures, and expectations about cur-
rent treatment. This kind of information is crucial for a person-centered approach to
care that takes into consideration the local sociocultural matrix of meaning.
KEY CLINICAL POINTS

• Coping and help seeking are strategies that individuals use to address their prob-
lems (e.g., emotional, relational, or somatic). Coping refers to the person’s own ef-
forts to deal with the situation, whereas help seeking refers to the steps taken by
the person to seek assistance from others.
• Information on coping and help-seeking behaviors from the Cultural Formulation
Interview can reveal what patients have found to be more or less useful for their
problem, which can inform clinicians about what patients desire from the current
treatment and what they want to avoid.
Questions
1. What are some examples of coping and help-seeking behaviors?
2. What clinical information can be obtained by assessing coping and help seek-
ing with the CFI?
3. What are the differences between coping and help-seeking behaviors?
4. What are some examples of coping and help-seeking behaviors that are strong-
ly influenced by culture?
5. What are the four components of the Coping and Help Seeking module?
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chol Rev 28:211–227, 2006
York, Freeman Press, 1988
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Sage, 2013
Patient-Clinician Relationship
Hans Rohlof, M.D.
Rob van Dijk, M.Sc.
The core Cultural Formulation Interview (CFI) contains only one question on
the patient-client relationship (question 16; see Appendix A in this handbook), but the
Patient-Clinician Relationship supplementary module is devoted entirely to this
topic (see Appendix C in this handbook). In this subchapter, we first describe why it
is useful for clinicians to assess the cultural aspects of the patient-clinician relation-
ship. We then describe the supplementary module and provide guidelines for its use.
Clinical Utility of Assessing

the Patient-Clinician Relationship
In mental health care, a positive patient-clinician relationship is of immense value
(Nussbaum 2013). Without a basic trusting relationship, patients will not be open and
honest about their thoughts, feelings, and behaviors, and the accuracy of psychiatric
diagnosis will be reduced. In addition, patients may choose not to follow the clini-
cian’s advice, not to alter their behaviors, not to adhere to medication, or not to en-
gage in psychotherapy; this lack of trust may lead to elevated rates of appointment
no-shows and premature discontinuation. As expressed by Franz Kafka's country
doctor, “To write prescriptions is easy, but to relate to people in other ways is diffi-
cult” (Kafka 1919).
Creating a relationship with patients is more challenging if patients and clinicians
differ culturally. Patients may report idioms of distress that are unfamiliar to the cli-
nician and may have different expectations about the clinical encounter, the course of
treatment, and potential treatment effects. Any of these differences may result in the
patient’s lack of trust in the clinician. A poor clinician-patient relationship may con-
tribute to the finding that the outcome of psychiatric treatment is much better when
patients and clinicians share a similar cultural background (Fassaert et al. 2010).
The patient-clinician relationship constitutes an ongoing area of research in trans-
cultural psychiatry. Kleinman (1980) pointed out the need to develop strategies so
145
that the expectations of the patient and the possible solutions offered by the clinician
can overlap. If the explanatory models of the patient and the clinician are too far
apart, treatment is more likely to fail. Moreover, Kortmann (2010) suggested that dis-
tinct phases of treatment require the clinician to maintain different therapeutic “dis-
tances” from the patient. He distinguished the following three stages:
1. An elementary-sympathetic stage, in which the clinician tries to establish a positive

and confidential relationship with the patient that facilitates trust and treatment
adherence
2. A diagnostic-therapeutic stage, in which the clinician has to make a diagnosis and
treatment plan, according to his or her professional standards
3. A personal stage, in which the clinician tries to integrate his or her observations and
analysis in a tailored treatment that makes sense for the patient
The clinician should be aware that a positive relationship with a patient will improve
treatment course and outcome by promoting progression through the three stages above.
A patient who remains too long in the first stage may feel trust, empathy, and understand-
ing but will not receive the necessary interventions from the clinician. If the second phase
is too extensive, the patient may admire the clinician in his or her professional role but
will miss a personal connection that motivates the patient to adhere to treatment and
change his or her behavior. The relationship built during the initial diagnostic and treat-
ment planning sessions is of crucial importance for the final outcome.
Cultural Aspects of Every Clinical Encounter

As in other contexts of human interaction, patients and clinicians produce, reproduce,
and transform culture in the process of receiving and providing mental health care,
in making contact, and in diagnosis and treatment. In other words, medical knowl-
edge is also cultural and mental health care can be seen as a product of culture (Taylor
2003). In addition, clinical interaction is influenced by differences in power between
patient and clinician in the clinical encounter, and between the social and cultural
groups to which they belong. Notably, health care professionals have the power to de-
fine patients’ worries and complaints and label them using classification systems
such as DSM-5 (American Psychiatric Association 2013) or ICD-10 (World Health Or-
ganization 1992) in ways that give the patient access to scarce social resources, such
as illness-related benefits and specific modalities of care.
Attention is often focused on linguistic and cultural differences in the clinical
dyad, which are generally seen as blocking communication and the health care pro-
cess. However, in every clinical encounter, medical culture and lay culture interact,
even when patient and clinician share the same cultural or ethnic backgrounds or
speak the same language (Boutin-Foster et al. 2008). Meanings of distress, complaints,
and symptoms are negotiated in a continuous process of interpreting, defining, com-
municating, and redefining, with the goal of a shared understanding of the patient’s
mental health condition and agreement about diagnosis and treatment.
Because of a lack of objective biomarkers of mental disorders, diagnosis and treat-
ment depend on the clinician’s interpretation of the patient’s interpretation of bodily
Supplementary Module 8: Patient-Clinician Relationship 147
and mental sensations, and of the way they are expressed, in ways that are socially
acceptable and understandable to the patient and his or her social network. This dou-
ble interpretation is complicated in a dyadic therapeutic relationship but is even more
complex when a third party is involved, especially in situations where relatives or
professional interpreters are present (Bot 2005; Willen 2011).
Cultural attitudes are co-constructed in interaction between patients and clini-
cians. Lewis-Fernández and Kleinman (1995) located culture not in the minds of indi-
viduals but rather between people in the medium of intersubjective engagements.
Patients’ attitudes toward clinicians are affected not only by factors such as cultural
norms, transference, countertransference, and patients’ prior experiences with health
care but also by other social and individual factors. This influences their views about
what is seen as appropriate to communicate about, how to communicate and interact
with the clinician, and what to expect from care.
Different Clinical Encounter Models

Globally, there are a great variety of models of clinical encounters within health care
systems, but the essence of all the models is that one person is in need of help and an-
other is in a helping position. Various factors, such as social and cultural traditions,
history, economy, ideologies, politics, and local contexts, affect the organization of
health care systems. In Western industrialized societies, clinical encounters have
shifted over the last half century from fairly authoritarian relations between clinicians
and patients toward a more egalitarian person-centered approach. The latter requires
that the clinician be more of a medical consultant and guide, while the patient is given
more decision-making power. In this model, the focus is shifted to self-management
on the part of the patient, resulting in an increased set of responsibilities for him or her.
In both primary care and mental health care in Western industrialized societies, cli-
nicians play several roles when carrying out a psychiatric assessment. They act as med-
ical experts, as well as helpers, guides, potential pharmacologists and psychotherapists,
and gatekeepers of health care. In multicultural environments, these clinicians encoun-
ter patients who are socialized in various physical and mental health care systems,
which they use simultaneously. Migrants and refugees face special situations. Mi-
grants’ expectations of the role of clinicians are diverse, as are their levels of trust in
health care generally and in providers specifically. Patients with a refugee background
may have experienced the mental health system as a collaborator in a repressive state
and may even have experienced health professionals as participants in torture.
Emotional Reactions Between Patients and Clinicians

Clinicians must remember that all kinds of emotions can occur during psychiatric treat-
ment. Cultural aspects of transference and countertransference are extensive (Comas-
Díaz and Jacobsen 1991). The clinician should be aware of his or her own ethnocentric
bias and of potential feelings of discrimination or overidentification, which can hinder di-
agnostic evaluation and treatment. In the unequal relationship of the clinician and the pa-
tient, it is difficult to express these feelings, but denying them is worse still. As early as the
first encounter, the clinician should try to identify his or her own emotional reactions.
Role of Reflection in Understanding Culture

Reflexive stance means trying to see oneself through the eyes of the other. Self-reflection,
or reflexivity, is a prerequisite for a comparative anthropological study of culture and so-
ciety (Hylland Eriksen 2004). It is a structured approach to trying, to some extent, to
take a step back from one’s own cultural framework. Reflexivity can also be a useful ap-
proach in clinical work in multicultural environments when trying to better understand
the perspective of the other.
Maintaining an attitude of self-reflection during ongoing clinical encounters may
prove difficult. Rudolph et al. (2001) address the value of reflecting after an event on
one’s thoughts, feelings, and actions to enhance one’s capacity for effective action in
complex social situations. They take the view that off-line reflection provides sufficient
distance in time and space to analyze and reexperience feelings, thoughts, actions, and
results that are confusing. This approach can be helpful for identifying blind spots in
assessment, including possible misunderstandings, miscommunication, and neglect of
alternative diagnostic interpretations. Self-reflection is also a way to identify reactions
of transcultural countertransference and to raise cultural awareness.
Why and When to Use

the Supplementary Module
The CFI facilitates exploration of cultural aspects of the interaction between clinician and
patient by examining their present relationship and context. The only core CFI question
on the patient-clinician relationship is question 16: “Sometimes doctors and patients mis-
understand each other because they come from different backgrounds or have different
expectations. Have you been concerned about this and is there anything we can do to pro-
vide you with the care you need?” The Patient-Clinician Relationship supplementary
module suggests additional questions for a more comprehensive exploration. Address-
ing cultural aspects of the clinical interaction enables both clinicians and patients to im-
prove their communication. The goal of the supplementary module is to assess the role of
culture in the therapeutic relationship. More specifically, the questions in the module fo-
cus on how patient and clinician experience, interpret, and shape their cultural tool kits or
repertoires, and how the development of the relationship is influenced as a result (Gregg
and Saha 2006). The module therefore focuses on the individual experience of culture
(Lakes et al. 2006)—that is, culture as it is experienced and performed by its individual
agents, in this case the patient and the clinician.
The supplementary module addresses the dual process of interpretation described in
the subsection “Cultural Aspects of Every Clinical Encounter.” The questions explore the
thoughts and beliefs that frame interpretation and help the clinician reflect on both inter-
pretational processes: how the patient understands the relationship with the clinician and
how the clinician understands the relationship with the patient. The module consists of
two separate sets of questions: one to be asked of the patient during the clinical encounter
and the other to facilitate self-reflection by the clinician after the interview. The module
can be used when core CFI question 16 indicates the need for further exploration (e.g., if
the patient reports substantial concerns about the relationship). Use of the module is also
recommended if referral sources report difficulty achieving a working alliance, if the pa-
tient specifically mentions his or her cultural differences with the clinician or relates con-
flictive clinical relationships in the past, or if the clinician finds the patient reluctant to
engage. In addition, the clinician’s own past experiences and assumptions can be power-
ful reasons to complete the module. The self-reflective section may be a useful adjunct to
care during every phase of treatment.

The supplementary module has 12 questions, organized as two sets: the first five are
asked of the patient, and the last seven encourage the clinician to take a self-reflexive
stance. The first set evaluates four domains in the clinician-patient relationship: expe-
riences, expectations, communication, and collaboration. The questions aim to ac-
complish the following objectives:
• Probe the thoughts and beliefs of the patient about health care in general, and
health care professionals in particular, that may influence the therapeutic process
in a positive or negative way
• Reveal past experiences that may impede or facilitate establishing an effective
therapeutic relationship
• Elicit the patient’s thoughts about the clinician and their future relationship
• Strengthen the clinician’s presentation as a thoughtful and open provider, who
can express his or her willingness to respect the patient, listen to the patient’s ex-
periences and take them seriously, and underscore the relevance attached to the
patient’s point of view
Questions 1 and 2 in the first set explore the patient’s previous experiences of
health care. The presentation of current complaints is contextual, depending on prior
clinical experience, present needs, and cultural traditions and expectations. Negative
experiences in the past, for instance, may explain the patient’s reluctance to inform
the clinician in an open way. Patients’ expectations that the clinician cannot meet—
for instance, immediate recovery from a chronic psychiatric illness or guaranteeing
scarce social resources or a good outcome in a legal matter—may be identified and
addressed early in therapy. In turn, the clinician can take into account in the treatment
plan what the patient experienced as helpful or difficult in the past and what the pa-
tient’s culturally patterned expectations are; sometimes, the clinician may also dis-
cover in the patient unexpected cultural and contextual resources.
Video 2 demonstrates how a prior negative experience can influence the current
patient-clinician relationship.
Video Illustration 2: What does that have to do with my lungs? (4:26)
In this video (highlighted in subchapter “Supplementary Module 1: Explanatory

Model”), a consultation-liaison psychiatrist begins his consultation interview
with a woman hospitalized for pulmonary disease by using the core CFI. The
second question of the core CFI (How would you describe your problem if you
were not talking to a physician?) quickly reveals that the patient is unaware that
her physicians have requested a consultation-liaison visit, apparently because
she is refusing diagnostic lung tests. The psychiatrist chooses to expand the basic
core CFI assessment with some questions from the Explanatory Model supple-
mentary module to clarify how the patient understands her illness. He hopes
that this will help him clarify the communication difficulties between the patient
and her inpatient team, because it appears very likely that there are differences
in the way that she and her physicians perceive her medical problems. Elicitation
of her explanatory model shows that she refuses the tests because she is afraid
that these will lead to her demise. Her husband was also hospitalized for his lung
problems and died during the admission; the patient is afraid the two are related.
It appears that she has not been able to resolve this concern with her inpatient
treatment team, a situation that demonstrates the value of using the CFI to elicit
more detailed information that can be used in a negotiation process to agree on
the next steps of evaluation and treatment.
This scenario also demonstrates how questions from different supplementary
modules can be combined seamlessly in a single interview, depending on the
needs of the situation. At the point that this video ends, for example, the psy-
chiatrist could choose next to pursue questions from the module on the pa-
tient-clinician relationship in order to clarify further the conflictive
relationship with the treatment team. The patient’s mistrust of her clinicians
and frank fear of tests may be motivated by many past experiences, including
not only her own loss of her husband in at least superficially similar circum-
stances, but may possibly also be a consequence of racist policies affecting
medical testing and treatment in the African American community. By provid-
ing a safe venue for her to express these concerns and expectations, the psychi-
atrist could help the patient develop a more collaborative relationship with the
treatment team.
Questions 3–5 focus on the present situation and identify impediments to an effec-
tive therapeutic relationship. Question 3 explores the patient’s views about the type
of clinician he or she would prefer. It is best not to assume that one knows the pa-
tient’s preferences but instead to inform patients openly about choices. If an inter-
preter is present, the patient’s preferences regarding the interpreter’s characteristics
and role should be accommodated. The influence of racial or ethnic differences in
therapeutic relationships is well known, but differences in gender, age, and religion
may also play a role.
Video 15 demonstrates how eliciting a patient’s clinician preference can lead to a
more effective patient-clinician relationship.
Video Illustration 15: In my own language (0:42)
The video “In my own language” shows how the core CFI question (16) on the
patient-clinician relationship can yield useful concrete information to guide
treatment planning even during an intake visit. Despite obvious English flu-
ency, this patient explains that conducting therapy in English is “harder, I have
to reach for words, I have to struggle.” This kind of information is best if elic-
ited during the initial visit, when treatment assignments are being decided,
and validates the inclusion of this item in the core CFI, despite its potential sen-
sitivity during an initial assessment.
It is important to keep in mind that matching on these characteristics is not always

obvious or preferred. Differences, furthermore, are not facts, set once and for all. The
initial preferences and the initially experienced differences may diminish as the ther-
apeutic relationship unfolds in a positive way. Question 4 opens a dialogue about the
patient’s doubts over being understood in the diagnostic phase. For example, talking
about homosexuality may be blocked if the patient and clinician share a religious
background that does not approve of a homosexual orientation. Question 5 aims to
promote a discussion about further collaboration.
The second set of questions in the Patient-Clinician Relationship supplementary
module offers guidelines for clinician self-reflection after the interview. These ques-
tions may help raise the clinician’s cultural self-awareness, including consciousness
about how his or her approach is framed by medical culture. The questions may also
promote the clinician’s awareness of potential stereotyping, of effects that the context
of treatment may have on the patient’s behavior, and of possible limitations of the
routines that clinicians develop and use in clinical practice to conduct evaluations
and plan treatment. The questions perform a dual purpose, guiding the clinician’s
own thoughts about the clinical encounter to be applied in future sessions and serv-
ing as discussion points for consultation with colleagues on the care of the patient.
Questions 1 and 2 of this second set promote the clinician’s reflection on feelings
that may occur in the patient-clinician relationship. Discrimination and social exclusion
often play an important role in the narratives of patients from underserved minority
groups. Being part of the dominant social group, and therefore not having personal ex-
perience with discrimination and social exclusion, may unintentionally hinder clini-
cians from adequately assessing their impact on the life of the patient. Furthermore, the
clinician can easily misjudge a patient when guided only by appearance. For example,
because of the clinician’s own assumptions, he or she may be surprised to discover that
a person wearing a religious head covering or what appears to be a “traditional” mode
of dress may espouse a thoroughly “modern” worldview.
Question 3 explores the impact of an interpreter on clinical communication. The
presence of an interpreter may cause the patient to be less open about thoughts and
feelings or, conversely, may improve trust and understanding. The clinician should
consider whether the patient worries that the interpreter may not be trustworthy or
sufficiently careful with confidential information. In small communities, the fear of
unwanted disclosure is often present. Occasionally, especially in the case of refugees,
patients may wonder about the allegiance of the interpreter to conflicting parties in
the country of origin.
Question 4 encourages the clinician to reflect more generally about how the pa-
tient’s cultural background may affect the clinician’s understanding of the problem
and its diagnosis, such as potential uncertainties about the diagnostic interpretation
of clinical signs and expressions of distress. Question 5 encourages a reflexive stance
toward the clinician’s own treatment recommendations and more general routines
for arriving at care planning. For example, the clinician may consider whether his or
her treatment plans usually take into consideration the patient’s conceptualization of
the problem and whether the clinician checks his or her assumptions about the pa-
tient and his or her own cultural orientations in evaluating therapeutic possibilities.
Questions 6 and 7 promote reflection on the clinician’s own prejudices and stereotyp-
ing biases and their potential role in the encounter with the patient.
Obstacles and Caveats When Using

the Module
A first obstacle is that the patient may wonder why the clinician is asking questions
that may at first glance seem to have little or nothing to do with his or her complaints.
Patients may not be accustomed to this kind of questioning, because most clinical set-
tings encourage a more passive stance by the patient in relation to the clinician. It is
important to introduce the questions in an appropriate way, and using the introduc-
tion to question 16 in the core CFI may help. In addition, the introduction to the sup-
plementary module suggests the following framing: “I would like to learn about how
it has been for you to talk with me and other clinicians about your [PROBLEM] and
your health more generally. I will ask some questions about your views, concerns,
and expectations.” If the patient still appears uncertain, the clinician may stress that
a good working relationship is important in mental health care and that it merits
some exploration with the patient.
A second obstacle is that patients may not understand the questions or may be un-
willing to disclose their thoughts about treatment or about the clinician, viewing
themselves as dependent on the clinician’s goodwill to access care. Sometimes, the
patient discloses thoughts more naturally when talking about past experiences than
when discussing the actual therapy situation itself. The clinician can also present ex-
amples from his or her clinical practice to convey to the patient that the clinician is
well acquainted with the patient’s situation.
A caveat to consider is the culture pitfall. This phrase refers to the clinician’s focus
on the culture of the group instead of on the individual patient as an agent who ap-
propriates “culture” in certain ways and is involved in specific social contexts (Klein-
man and Benson 2006). It also refers to an operationalization of culture as a set of
static properties of patients instead of as a fluid intersubjective system of meanings
and practices (Kirmayer 2012). Above all, patients usually do not like to be treated as
a representative of an ethnic group instead of as an individual (Feldmann et al. 2007).
Another caveat is that both patients and clinicians may refer to “culture” as a de-
fense mechanism: the patient may do so to avoid talking about personal issues and to
legitimate his or her choices, whereas the clinician may do so to argue that problems
that occur in treatment are externally caused and not therapist related. It is important
to avoid talking about culture in general terms or to use it as an argument. The clini-
cian should focus instead on the actual behaviors and views of the patient and his or
her social system in everyday life. As Kleinman (2005) stated, it is important to keep
in mind this injunction: “First, do no harm by stereotyping.”
Conclusion
In this subchapter, we have provided a theoretical background to the evaluation of
the patient-clinician relationship. We have described the supplementary module on
this topic, shown how to implement it, and ended by describing possible obstacles
and caveats to its use. Even if the clinician does not ask the questions verbatim, he or
she should keep the topics of the module in mind during every phase of mental health
assessment and treatment to enhance his or her reflexivity and cultural awareness.
KEY CLINICAL POINTS

• In psychiatric practice, a good patient-clinician relationship is of immense impor-
tance, reducing treatment nonadherence and nonretention.
• Transference and countertransference are affected by culture, including cultural
similarities and differences between patient and clinician.
• The Patient-Clinician Relationship supplementary module can help the clinician
obtain a quick and relatively thorough evaluation of the relationship to forestall later
problems.
Questions
1. What is reflexivity in intercultural mental health care?
2. What are the goals of each of the two sets of questions in the Patient-Clinician
Relationship supplementary module?
3. When in the process of care is it appropriate to use the questions in the Patient-
Clinician Relationship supplementary module?
4. What are some obstacles to the use of the module?
5. What are some caveats for the use of the module?
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School-Age Children
and Adolescents
In this subchapter, we examine the importance of integrating the DSM-5

(American Psychiatric Association 2013) Cultural Formulation Interview (CFI) into a
developmental and systemic perspective in clinical practice with youth and describe
the use of the School-Age Children and Adolescents supplementary module (see Ap-
pendix C in this handbook). Integrating a cultural formulation dimension into the
usual biopsychosocial assessment of youth must rely on a multi-informant model of
interviewing. The CFI supplementary modules—including Cultural Identity, Explan-
atory Model, Psychosocial Stressors, and Coping and Help Seeking, among others—
are all important in child and adolescent psychiatry, because unpacking the complex-
ity of family and systemic issues may clarify the diagnosis and inform the treatment
plan. In this subchapter, we address three of the most common challenges clinicians
are likely to face when using the CFI in child and adolescent psychiatry: 1) accessing
the voices of school-age children, including perceptions or dissonances related to nor-
mality and problem definition, assigning of cultural meaning, code switching, accul-
turation, racism, and language issues; 2) uncovering the evolution of feelings of
belonging and multiple identities in cultural minority youth, such as hybridity and
creolization of identities and daily realities of immigrant and refugee or undocu-
mented communities; and 3) negotiating the gaps and divergent frames of reference
between youth and their multiple caretakers (e.g., family, schools, youth protection
agencies, clinicians).
Cultural Formulation in
Child and Adolescent Psychiatry
The literature on culturally competent clinical practice underlines the importance of
taking into account cultural and contextual factors throughout assessment in child
psychiatry (de Anstiss et al. 2009; Measham et al. 2014; Rousseau et al. 2013). Some
specific changes are required in the process of assessment to address linguistic and
156
Supplementary Module 9: School-Age Children and Adolescents 157
cultural breaches, not only between the family and the clinician but also among fam-
ily members and numerous caretakers or agencies involved, including school social
service agencies and day care programs.
Working with interpreters in child psychiatry must take into account the develop-
mental level of the child and his or her ability to participate in linguistic interpretation
and to comprehend translated written material. In the clinical setting, clinicians must
also examine the effect of intergenerational differences in the alliance between the in-
terpreter, the parents, and the child (Rousseau et al. 2011). It has been well established
in the literature that immigrant children may differ from their host country same-age
peers in that they present either more or fewer emotional and behavioral symptoms
(Stevens and Vollebergh 2008). This difference is particularly important in the case of
refugee children, who are exposed to multiple sources of adversity in both the pre-
migration and the postmigration periods (Fazel et al. 2012). Recently, the question of
cultural identity in immigrant and refugee youth, which has always been a key ele-
ment of the acculturation process, has been emphasized in research because of its im-
portance in the context of the intercommunity tensions associated with international
conflicts and fears (Britto 2008). All of these factors, and others that are operational-
ized in the CFI, have a key role in child psychiatry and often need to be elicited in the
assessment process in order to reach the comprehensive understanding that is needed
to formulate an integrated treatment plan relevant to the family and the rest of the
child’s network.
However, literature on the cultural formulation approach and its application in
work with children and adolescents is scant. A few clinically oriented papers describe
its utility and question some of the limitations of the DSM-IV (American Psychiatric
Association 1994) Outline for Cultural Formulation (OCF) for this population (Aggar-
wal 2010; Novins et al. 1997; Rousseau et al. 2008; Takeuchi 2000).
Discussing the application of the OCF to American Indian children, Novins et al.
(1997) emphasize the difficulty of assessing cultural identity in children both because
of the complexity of identity construction at this stage of life and because of the nu-
merous identity shifts that may occur during the adolescent period (Canino and
Spurlock 2000). Takeuchi (2000) demonstrates how cultural formulation can inform
the development of an alternative treatment plan that takes into account family dy-
namics, explanatory models of illness, and sense of community. He also emphasizes
the importance of taking time to establish a strong alliance and to formulate a cultur-
ally appropriate treatment plan. These few publications highlight the usefulness of
the OCF in child psychiatry but also demonstrate that it may not always be an easy
tool to implement in practice.
The CFI supplementary modules represent an important step in supporting clini-
cians working with families by providing specific questions to facilitate the assess-
ment of the cultural dimensions of child psychiatric problems. To inform the
development of training programs and clinical guidelines, the dissemination of the
School-Age Children and Adolescents supplementary module will need to be sup-
ported in the future by a rigorous evaluation process. Although the core CFI is rele-
vant individually to each youth, the supplementary module amplifies the collateral
information (e.g., from family, peers, and school personnel) necessary to formulate an
understanding of the youth’s crucial developmental influences. The supplementary

module can help the interviewer identify cultural and contextual influences that may
hinder or facilitate developmental mastery.
Three principles should govern the application of the School-Age Children and
Adolescents module and, to some extent, the use of any other supplementary mod-
ules with youth. First, brevity is essential; the validity of the assessment and the qual-
ity of the alliance require that the youth not be overburdened by the length of the
interview. Because the patient’s attention span and concentration increase with age
and developmental stage, the culturally sensitive clinician should resist the desire to
verbalize or gather all historical data at one time. The clinician should consider using
other modalities, such as observation, drawing, or play, as auxiliary tools during the
session, selecting carefully which cultural dimensions to investigate first. Second, the
questions need to be adapted to the child’s or adolescent’s cognitive and linguistic de-
velopment, particularly because the questions do not always correspond to chrono-
logical age. Cultural and contextual factors, including the impact of language
differences and the dislocation experiences of refugees or immigrants, influence the
relative maturity (or delay) in specific cognitive domains. Third, as in any standard
biopsychosocial child psychiatry assessment, it is pertinent to include the collateral
information gained from the perspective of the significant adults in the various life
environments of the child.
Use of CFI Supplementary Modules in

Child and Adolescent Psychiatry
The School-Age Children and Adolescents supplementary module does not replace
the other modules of the CFI, which can also be used in child psychiatric assess-
ments, particularly when the parents have undergone complex trauma, periods of
absence due to migration trajectories, or reunification issues. The module has been
developed to help the clinician explore age-related cultural dimensions with the
youth themselves. Special care has been taken to avoid assigning a specific cultural
identity to the youth by the examiner or collateral informants. The questions are pur-
posefully indirect to allow the child or adolescent to express his or her feeling of be-
ing special or different without the clinician imposing the idea that he or she is in any
way different. In terms of content, the questions are designed to yield the youth’s
representations of normality at home, at school, and with friends and some of the
challenges of growing up.
The supplementary module is composed of four sections. The first section (ques-
tions 1–7) addresses the youth’s feelings of age appropriateness in different settings
(i.e., at home, at school, among friends), the perception of being different or special
(in the youth’s own view or the view of the family), and the pride or validation even-
tually associated with awareness of these differences. The second section (questions
8–10) targets age-related stressors and supports. The third section (questions 11–14)
seeks to elicit expectations various people have of the child or adolescent and to un-
cover potential contradictions among these divergent expectations (e.g., a migrant
family may expect a child to spend a lot of time on chores, but a teacher may consider
these expectations to be abusive). The last section (questions 15–20) addresses mark-
ers, rituals, or processes in transition to adulthood or maturity. This set of questions
is usually only for adolescents—that is, youth experiencing puberty. This developmen-
tal period, puberty and the periods immediately before and after, is universally con-
sidered important, although the specific concept of adolescence is not necessarily as
formulated or well accepted in some communities as it can be in the European–North
American context. This transition is commonly marked by celebrations or rituals that
may be gender specific (e.g., the quinceañera for Latin American girls or the bar mitz-
vah for Jewish boys). The clash between youth culture in the host society and immi-
grant families’ ideas about the transition to adulthood is a common source of conflict
or challenge during the acculturation process. Dating, sibling responsibilities, finan-
cial responsibility toward family expenses, and degrees of autonomy are some fre-
quent sources of tension that emerge because of diverging cultural norms. These
familial transitions call for respectful acknowledgment of cultural norms and cultural
differences that leaves room for mediation.
The supplementary module has an Addendum for Parents’ Interview that can be
used to elicit information from the adult caretakers of infants and preschoolers. In-
quiring about the child’s name or play activities is usually an easy route to rapport
and often a nonthreatening way to address culture. Many names have special mean-
ings that convey information about family dynamics (e.g., authority, degree of adhe-
sion to tradition, or transgression of family and community practices) and about
parental and extended family expectations regarding the particular child. Classic de-
velopmental milestones, such as walking, sleep habits, and toilet training, may vary
culturally. Markers of autonomy (e.g., eating and dressing alone), assessment of age-
appropriate risk taking, and forms of disciplining are also culturally constructed.
Without taking into account intercultural differences among clinician, society, and
family in the evaluation of those aspects of development, clinicians may arrive at in-
accurate diagnoses or unsuccessful intervention plans (Hassan et al. 2011). The com-
plexity of multiple language exposures at home and at school should also be actively
elicited (Toppelberg and Collins 2010).
The School-Age Children and Adolescents module can be integrated into the in-
take assessment or a subsequent interview, in conjunction with the core CFI and other
supplementary modules. It should not be administered as if it were a semistructured
interview, with a preordained, fixed order of questioning. The child and adolescent
clinician should learn to weave the CFI questions and dimensions into his or her
usual comprehensive assessment. For example, the evaluation with the parents re-
garding pregnancy and delivery represents an excellent opportunity to ask about the
child-naming process and the eventual meaning of the name; similarly, documenting
a patient’s developmental milestones can easily include questions about autonomy
and discipline in the culture of origin, and likewise with other components of the
usual clinical evaluation. Training child and adolescent clinicians to use all the com-
ponents of the CFI can be done either through modeling—by watching an interview
integrating a CFI perspective—or through case discussions that emphasize the signif-
icance of the cultural material, identify any missing information, and help clinicians
and trainees integrate all available information into a case formulation to guide treat-
ment planning.
Interviewing School-Age Children

Early in development, children grow up apprehending a world where they may be
exposed to various cultural frames of reference. From age 4 years, they are able to dis-
tinguish their own cultural group’s features and characteristics, especially those re-
lated to language, ethnicity, and visible minority status (Aboud 1993). As they
individuate, youth learn how to navigate the cultural differences between home and
a complex and heterogeneous outside world, including day care programs and
schools. However, their capacity to articulate the cultural dimensions of their experi-
ence evolves more slowly, as they master language, learn to abstract, and develop
cognitively. To access the cultural dimensions of their experience, interviews of
school-age children should aim to elicit some of the internalized cultural norms and
expectations that structure their perceptions of themselves and their roles in different
contexts with various caregivers. These perceptions and mental representations
should be distinguished from cognitive distortions associated with psychopathology
or neurodevelopmental disorders. Children’s participation in the assessment process
does not imply that they are expected to become key informants about their cultures
or that they can be expected to interpret their cultures for the clinician. Each family
and child narrative is unique and may vary depending on context and other influ-
ences. The supplementary module suggests key questions to explore youth’s percep-
tions of themselves and their role in the different environments they navigate,
including the similarities and differences between the family’s response to the
youth’s vocational goals, athletic interests, or artistic pursuits and the youth’s percep-
tions of the host culture’s responses to these activities. The following case vignette il-
lustrates how the supplementary module may help elicit these perceptions.
Case Vignette
Hussein is a 9-year-old Eritrean refugee who was referred to child psychiatry by his Ca-
nadian school, which had recently expelled him and refused to take him back unless he
was evaluated by mental health services for possible violent outbursts and unpredict-
able oppositional behavior. Hussein’s mother explained that he was the oldest of five
children and that she had to raise the children alone because her husband had been
killed in the Eritrean civil war. Because of the war, Hussein had not been educated, and
he was experiencing severe academic difficulties and increasing behavior problems. He
had recently bitten another child and had hit two teachers before he was expelled. Dur-
ing the family phase of the interview, Hussein was withdrawn and almost mute. How-
ever, he agreed to stay with the clinician and be interviewed with the help of an
interpreter. A bit reluctantly, he agreed to work on a puzzle but refused to speak about
the problems at school.
Interviewer: Do you feel you are like other children your age?
Hussein: (Shakes his head no)
Interviewer: Do you feel different from other children here in Canada or in Eritrea?
Hussein: Both. (Frowns)
Interviewer: What would an Eritrean mother think of a son like you?

Hussein: (No answer)
Interviewer: What would an Eritrean grandmother think of a son like you?
Hussein: (In a muffled voice, visibly anxious) She would slit my throat.
This response opened a window to explore Hussein’s negative self-image. He felt irre-
sponsible and very apprehensive that he had not been a good example for his siblings
as the oldest son. His school difficulties had led to remedial measures and placement in
a special class, which he experienced as a terrible humiliation. He was convinced that
school personnel considered him “crazy” or “bad,” and these projected identifications
led to his enactments of both “crazy” and “bad” behavior, leading to an escalation in
the conflict with the school.
After the interview with Hussein, his mother acknowledged that she felt the school
had hurt her son’s sense of dignity and that his anger explained the intensity of his act-
ing out. She felt that she could not criticize the school for fear of retaliation against Hus-
sein and her other children, so she had kept her understanding of the situation to
herself. The management plan included a change of school, because the original school
would not agree to change their view of Hussein as violent and dangerous and to rein-
tegrate Hussein into a regular classroom with academic support. Although Hussein
continued to struggle academically throughout his schooling and remained quite hy-
peractive, his violent behavior completely disappeared and he successfully graduated
from high school.
Hussein was caught between two very painful representations of himself. For the
school and the host society, he was “crazy,” and referral to the child psychiatrist embod-
ied the confirmation of this view, which explained his reluctance to engage in the as-
sessment. For his family (and his culture of origin), he was a failure because he could
not fulfill his duties as the oldest son, especially in the absence of his father, and was a
terrible example for his siblings. Partially restoring his self-image in these two worlds
was crucial to the therapeutic process.
Use of the CFI modules with parents (including the Addendum for Parents’ Inter-
view of the School-Age Children and Adolescents module) may complement the as-
sessment of the youth and offer useful information on illness explanations, aspects of
cultural identity, and other factors that are relevant to understanding family dynam-
ics and child-parent differences in appraising the impact of the youth’s symptoms or
behaviors. The symptom presented by the child may be understood differently by the
youth and the parents in spite of the fact that they share a common culture at home.
Interviewing Adolescents:
Eliciting Identities and Affiliations
Because of rapid developmental changes and the resulting shifts in social positioning,
adolescence is always a period of identity formation, which for many youth living in
multicultural settings will also include a series of identity negotiations (Akhtar 1995;
Song 2004; Ungar 2008). In a clinical encounter, it could be incorrect to presume that
an adolescent will have the same identity as his or her parents and elders or that the
adolescent will necessarily be more acculturated than they are. Youth identities and
affiliations can be elicited using the Cultural Identity supplementary module. How-
ever, it is important to understand that adolescents are far more vulnerable than
adults, because their identities are in formation and thus are more fluid. The inter-
viewer must be aware that the identity endorsed by the youth may shift with the in-
terview context and with social circumstances.
Cultural Formulation and Systemic Interactions

Every aspect of a youth’s environment plays a key role in understanding the individ-
ual’s problem and in formulating a treatment plan. This multiplicity of perspectives
within the assessment process is a fundamental asset to understanding the cultural
frames of reference, not only of child and family but also of institutions, professionals,
and other significant caretakers, who also engage the situation through a cultural
lens. Often in CFI assessments, it is important for the clinician to complete a geno-
gram with parents, once an alliance is established, to understand whether there are
extended family members who may be geographically distant yet have a substantial
impact on decision making, attachment roles, and emotional support in a way that is
integral to the intervention plan.
Addressing institutional racism is always delicate when the clinician wants the in-
stitution to be a protective place for the child and family as part of establishing cul-
tural safety. It is important not to deny the distress of institutional racism or abuses
caused by prejudice, because this form of complicity may harm the family and the
therapeutic alliance (Fernando 1995; Stanley 2009). The CFI can help to identify these
issues, delineating their role in the clinical presentation, by taking these tensions into
account and clarifying the need for professional advocacy.
Conclusion
The core CFI and the supplementary modules are useful tools for working with chil-
dren, adolescents, and families. As in working with adult patients, all of the CFI mod-
ules may be helpful at different points in diagnosis and treatment planning with
children and adolescents. Most often these assessments should include input from
family (including extended family and/or family in the country of origin as needed),
the day care program or school, and occasionally other legal actors such as youth pro-
tection services or the police. The cultural formulation approach not only should ap-
ply to the family and the youth interviews but also should inform a broader attempt
to document the diverse perspectives of all the caretakers involved, because all of
them are embedded in cultural predicaments and perspectives.
KEY CLINICAL POINTS

• Because the perceptions of children and adolescents are influenced by the various
cultures to which they belong (at home, at school, in their community, and among
their social networks), eliciting a multiplicity of perspectives is necessary to under-
stand the cultural aspects of the individuals’ mental health problems.
• The School-Age Children and Adolescents supplementary module of the Cultural

Formulation Interview helps the clinician to elicit, through simple age-appropriate
questions, cultural elements contributing to the assessment and formulation of a
treatment plan, such as the norms and expectations that structure a youth’s per-
ception of self and of his or her role.
Questions
1. Who should be considered as an informant to understand the cultural aspects
of a youth’s mental health problem?
2. What are some of the factors to keep in mind when interviewing a child?
3. What are some aspects of child development that may vary with culture?
4. To what extent is adolescence a universal concept?
5. What characterizes cultural identity during adolescence?
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ugees: a review of the literature with implications for policy, practice, and research. Trans-
cult Psychiatry 46(4):584–607, 2009 20028678
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tled in high-income countries: risk and protective factors. Lancet 379(9812):266–282, 2012
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York, Routledge, 1995
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ing immigrants and refugees. Can Med Assoc J 2011. Available at: http://www.cmaj.ca/
content/suppl/2010/06/07/cmaj.090313.DC1/imm-childmal-12-at.pdf. Accessed No-
vember 14, 2011.
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in Cultural Consultation: Encountering the Other in Mental Health Care. Edited by Kir-
mayer L, Rousseau C, Guzder J. New York, Springer, 2014, pp 71–87
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ical demonstration with American Indian children. J Am Acad Child Adolesc Psychiatry
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Suggested Readings
Measham T, Heidenreich-Dutray F, Rousseau C, et al: Cultural consultation in child psychiatry,
in Cultural Consultation: Encountering the Other in Mental Health Care. Edited by Kir-
mayer L, Rousseau C, Guzder J. New York, Springer, 2014, pp 71–87
Rousseau C, Measham T, Bathiche-Suidan M: DSM-IV, culture and child psychiatry. J Can Acad
Child Adolesc Psychiatry 17:69–75, 2008
Older Adults
Ladson Hinton, M.D.
In this subchapter, we present theoretical foundations and practical

strategies for the cross-cultural assessment of older adults using the DSM-5 (Ameri-
can Psychiatric Association 2013) Cultural Formulation Interview (CFI). This type of
cultural assessment assumes clear public health significance in light of population
trends worldwide with respect to the growth and increasing ethnic and cultural di-
versity of older adult populations. The Older Adults supplementary module (in Ap-
pendix C in this handbook), along with the Caregivers supplementary module (also
in Appendix C) and the CFI–Informant Version (in Appendix B), can assist clinicians
in adapting the core CFI (in Appendix A) to meet the needs and circumstances of
older adults, thereby facilitating more effective cross-cultural mental health assess-
ment and initial treatment planning for older adults. This subchapter addresses the
rationale for the Older Adults module to supplement the CFI, describes the structure
and content of the Older Adults module, and provides clinicians with guidelines on
use of this module and the other CFI components.

The aging population has grown because of medical innovations that have increased
life expectancies to unprecedented levels. According to the Institute of Medicine
(2008), the population of Americans age 65 and older is expected to double to 20% of
the total population by 2030. In the mid-twentieth century, only 14 million people
age 80 and older lived on the entire planet, a number that will skyrocket to 400 mil-
lion by 2050 (World Health Organization 2012). This increase in the elderly popula-
tion is also expected to increase the burden of mental health disorders, particularly
of memory-impairment illnesses such as dementia, as people live longer. For exam-
ple, 35.6 million people in 2012 were living with dementia worldwide, and this num-
ber is expected to double by 2030 and more than triple by 2050 (World Health
Organization and Alzheimer’s Disease International 2012). The rise in life expectan-
cies has led to widespread social transformations, such as reducing traditional kin-
ship ties from the extended family to the nuclear household with a consequent
165
reduction in the extent to which family members provide care to elderly relatives
(Sokolovsky 2009). Meanwhile, the responsibility of caregiving has shifted to a
health care system that cannot adequately supply geriatric psychiatrists: in 2011,
only 43% of the 131 postdoctoral fellowship positions in geriatric psychiatry were
filled, an insufficient number to treat the 14%–20% of the elderly population suffer-
ing from a mental disorder (Institute of Medicine 2012). This lack of specialist re-
sources increases the likelihood that mental health clinicians from all disciplines will
treat older adults. Therefore, mental health clinicians would benefit from a basic in-
troduction to cultural issues relevant to the care of this population.
We believe that clinicians who work with elderly patients would benefit from
keeping two types of cultural competence in mind. First, we recommend that clini-
cians explore the unique identities of their patients and how these identities relate to
their clinical care (see subchapter “Supplementary Module 6: Cultural Identity”).
Second, we recommend that clinicians formulate the care of elderly patients based
on common needs and challenges of this developmental phase. Culture shapes the
attitudes, beliefs, and expectations of all humans about developmental transitions,
such as retirement from work (Luborsky and LeBlanc 2003), the process of aging
(Goldstein and Griswold 1998; Schulz and Heckhausen 1999), and the meanings and
rituals associated with death (Hallenbeck et al. 1996). For this reason, cross-cultural
gerontologists have emphasized the need to disentangle universal processes of ag-
ing common to all people and specific aspects of aging that vary based on individual
cultural characteristics (Cattell 1989). The experience of aging is formed not only
through interactions with close associates such as family and friends but also by so-
cial, political, and economic structures in which aging is embedded (Edmonson
2013), including the structures of the health care system. For example, culture influ-
ences the way elderly patients access health services, and attitudes vary on what
constitutes elder abuse based on familial role expectations (Simpson 2005), the per-
ceived need for treatment of disorders, such as dementia, that are considered a nat-
ural response to aging (Sadavoy et al. 2004), expectations about whether medications
are useful (Chia et al. 2006), and which family members can serve as health care prox-
ies for decision making (Rubinstein 1995; Morrison et al. 1998). Culture also influ-
ences how the elderly adopt self-care practices to maintain essential activities of
daily living, and clinicians can inquire about these practices as a window into body
image, psychological resilience, and cross-generational social relationships (Dill et
al. 1995). In addition, culture influences how providers diagnose patients with age-
related disorders; for example, international medical graduates, compared to U.S.
graduates, diagnose depression less frequently in elderly individuals based on their
own cultural attitudes and biases, which clearly impact treatment provision (Kales
et al. 2006).
We acknowledge that culture envelops all of us in the health care system, not only
patients or their close associates. A thorough and comprehensive cultural assessment
should therefore account for the distinct characteristics of all participants in health
care, including clinicians. Because of these complex interactions, specialists in cul-
tural mental health have highlighted the need for a systematic method to elicit the re-
lationship between cultural conceptions of aging and multiple domains of illness
Supplementary Module 10: Older Adults 167
experience. A recent survey of textbooks on geriatric medicine and geriatric psychia-

try has shown that authors either omit any mention of the need for cross-cultural as-
sessment or suggest it without offering clear guidelines or methods (Aggarwal 2010).
This led to suggestions that the DSM-IV (American Psychiatric Association 1994)
Outline for Cultural Formulation (OCF) could be adapted for use with the elderly
population based on the significant evidence base of its use in younger patients (Ag-
garwal 2010, 2013). The OCF’s revision into the core CFI with a supplementary mod-
ule for older adults offers standardized instructions and questions for clinicians to
simultaneously assess cultural needs based on individual identities and common
challenges in this developmental phase.

The overall goal of the Older Adults supplementary module is to assist clinicians in
gathering information to assess the role of cultural conceptions of aging and aging-
related transitions in the patient’s illness experience. Fundamental to this assessment
is the notion that cultural concepts of aging can be important sources of identity, ill-
ness meanings, and interpersonal processes and experiences that are of direct rele-
vance to the core domains of the CFI. The Older Adults module fleshes out these
connections, offering concrete examples of questions to assist the clinician. The mod-
ule consists of 17 open-ended questions that fall into six broad categories of inquiry.
As in other supplementary modules, the questions in this module amplify particular
sections of the core CFI (which parallel those in the CFI–Informant Version). In this
section, we discuss important sections of this module and their relationships to the
core CFI.
The first and last sets of questions in the Older Adults module address issues of
identity as they relate to aging, but in very different respects. The first set, concep-
tions of aging and cultural identity, includes three questions that explore how older
adults draw on culturally constructed concepts of aging and stages of the life cycle to
create their own identities. These questions parallel the core CFI section on cultural
identity (i.e., questions 8–10). Understanding the vocabularies that a person uses to
describe his or her positioning in the developmental cycle (e.g., “an old person”) and
their associated meanings can be useful when these terms are invoked in other parts
of the interview (e.g., “I am this way because I am old”). The final set, positive and
negative attitudes toward aging and the clinician-patient relationship, includes ques-
tions 15–17. These questions (especially question 16) might evoke, for example, the
experience of discrimination or stereotyping that older adults experience based on
perceptions of how others treat them.
Aging can influence illness meanings through two pathways that are highlighted
in this module. First, aging can be a powerful source of explanations for illness-related
changes (e.g., “this is just part of getting old”); the specific meanings of growing old
and associated expectations may vary substantially across cultures. The module’s sec-
ond set of questions (4 and 5) addresses how conceptions of aging shape explanatory
models of illness and related coping strategies, directly expanding the core CFI ques-
tions on causes of the illness episode (core CFI question 4) and self-coping (question
11). Being older is associated with challenges and transitions that impinge on the ex-
perience and meaning of mental health problems. Older adults, for example, are much
more likely than younger individuals to experience comorbid medical illness and as-
sociated challenges, such as medical treatments, functional disability, and increased re-
liance on others for assistance in completing activities of daily living. These challenges,
in turn, influence how patients understand their mental health problems (e.g., as a
result of a medical condition) and their approaches to coping. The third set of ques-
tions (6–9) probes relationships between physical health and mental health and may
assist clinicians in understanding frameworks of explanation that may be relevant to
older adults’ conceptions of their mental health problems (core CFI question 4) and
self-coping (question 11).
Video 16 presents the perspective of an older patient on his injury and recovery.
Video Illustration 16: After the fall (4:00)
The CFI draws upon a definition of culture that includes the background, de-
velopmental experiences, and current social contexts of an individual and their
resulting effect on perspective. The video “After the fall” highlights develop-
mental experiences around aging as a source of dynamic cultural meaning-
making during an illness, using questions from the supplementary module
Older Adults. The interviewer begins with a series of open-ended questions on
how age has affected the individual’s current problem of a broken leg and sub-
sequent recovery. The interviewer also encourages speculation on how being
younger could have made a difference. The individual responds that being
younger would not have made a difference to the conditions leading him to fall
but that the rehabilitative exercises might have been “easier or faster.” He also
states: “I didn’t consciously think, ‘Yes, my age is a problem for this, or yes, I
am getting more help because I am older for this.’” However, when the inter-
viewer probes beyond physical factors to “context and life” in investigating ad-
ditional domains of culture, the individual answers, “I have an extraordinary
wife and she was there with me through this whole thing.” He also adds with
a laugh, “I wouldn’t have had her if I was younger.” We get a glimpse of how
this individual views aging as a life phase filled with companionship and
views his wife as an “advantage” of his age. The CFI invites clinicians to con-
sider how members of a social network act as sources of support or stress dur-
ing an individual’s illness, recognizing that culture is transmitted within social
groups such as families: the man in this video names his wife as a clear support
and connects their positive relationship to aging.
For a subset of older adults, particularly those with functional limitations and
frailty, older age brings with it increasing reliance on others for support, such as fam-
ily members, friends, and paid workers. These social networks can be important for
practical assistance with mental health treatment and act as sources of either emo-
tional support or strain and conflict. For example, a perceived lack of support from
family caregivers can be stressful for patients if caregivers violate culturally cali-
brated expectations of familial support. Questions 10–12 of this supplementary mod-
ule assess the quality and nature of social supports and caregiving from the patient’s
perspective. Answers can provide clinicians with an understanding of the social con-
text of illness that is meaningful for cultural formulation.
Video 17 focuses on social support, both physical and psychological, and the ex-
perience of recovery.
Video Illustration 17: Getting back on my feet (3:46)
In this video, the interviewer transitions to the domain of the supplementary mod-
ule on the quality and nature of social supports and caregiving by asking how re-
covery has changed relationships with friends and family, including with his wife.
The man says emphatically, “It would be hard to imagine better support from col-
leagues—I had people come to the house so that we could get some work done....
It made it pretty easy for me to do the things I had to do to get back on my feet.”
These answers illustrate that people in his social network banded together for his
psychological support and to facilitate activities of daily living such as work and
basic ambulation. These answers also disclose this individual’s resilience in refus-
ing to compromise his baseline functioning prior to the fall. We learn about illness
severity through certain sentences from the discussion on recovery: “It’s uphill....
Any little sign of improvement is a big deal.” These statements reveal a sense of
the difficulties he has endured. He also adds, “It’s bizarre...being wheeled through
an air terminal flat on your back, looking up and seeing people who could walk.”
The interviewer recognizes that the individual is expanding the conversation be-
yond physical pain to discuss the psychological effects of illness. The interview
closes with the individual clarifying, “They have pills for the pain, but if you’re
alert—which I was—the situation is very, very strange.” Such statements impart a
perspective on what is at stake for the individual during illness beyond the bio-
medical information obtained in a typical clinical interview, which can often be fo-
cused on symptom elicitation to make a diagnosis.
Guidelines for Clinical Use of CFI Components

In adopting what we term “the CFI approach” with older adults, we believe that clini-
cians can avail themselves of all three CFI components: 1) the core CFI, 2) the Older
Adults supplementary module, and 3) the CFI–Informant Version. Each tool varies in
terms of audience, length, and type of information elicited. In this section, we suggest one
possible strategy for using the CFI with older adults. We hope that clinicians regard these
components as complementary and synergistic rather than conflicting or confusing.
Core CFI
We believe that the core CFI can be used to begin the initial assessment of all patients
in any clinical encounter. As explained in Chapter 2, “The Core and Informant Cul-
tural Formulation Interviews in DSM-5,” the DSM-5 field trials actively recruited pa-
tients between ages 18 and 80 (American Psychiatric Association 2013). Patients of a
wide range of ages were included to test the feasibility, acceptability, and clinical util-
ity of the CFI among different patient groups. Analyses showed that clinicians can use
the CFI with older adults during initial assessments just as with younger adults.
Therefore, we recommend that general clinicians use the core CFI for all older adults.
Older Adults Supplementary Module

We believe that the Older Adults module can be used to complement content elicited
with the core CFI. Questions and techniques from this supplementary module as-
sume that clinicians will have a working understanding of the core CFI. For example,
substitution of “[PROBLEM]” with a patient’s term in the supplementary module is
designed to increase patient satisfaction and build therapeutic alliance as in the core
CFI. At the same time, this supplementary module includes material unique to the
cultural concerns of older adults, and there may be clinical scenarios when this con-
tent would be especially important. Mental health clinicians who work closely with
primary care providers or geriatricians may find the third set of questions, influence
of comorbid medical problems and treatments on illness (questions 6–9), to be help-
ful. Similarly, clinicians such as social workers, physical therapists, and occupational
therapists who routinely perform functional assessments may benefit from the ques-
tions on quality and nature of social supports and caregiving (questions 10–13).
Thus, depending on the clinical circumstances, clinicians may choose to use only
some of the questions from the supplementary module in conjunction with the core
CFI. In addition, the questions in the supplementary module may be used during the
clinical visit when the core CFI is used or later, in follow-up visits. Clinicians working
with older adults may find that items from other supplementary modules are useful
as well. For example, a clinician working with a frail older adult who is accompanied
by a family caregiver may find the Caregivers module particularly useful for eliciting
a more thorough understanding of the caregiver’s perspective as a way of building
rapport and developing culturally informed strategies to support the patient.
CFI–Informant Version
When a patient may not be able or willing to provide a detailed account of his or her
illness, the CFI–Informant Version may help clinicians understand relevant cultural
concerns from the patient’s close associates. Neuropsychiatric conditions such as Al-
zheimer’s disease, Parkinson’s disease, and other dementias may affect memory, cog-
nition, and other executive functions that are necessary for patients to complete the
medical interview. General medical conditions such as diabetes, stroke, chronic pain,
osteoporosis, imbalance, and falling may also lead patients to depend on close asso-
ciates. In these instances, collateral information from informants can provide a fuller,
richer picture of the patient’s lived illness experiences, assuming that informed con-
sent has been obtained.
Conclusion
We encourage clinicians to share their experiences using the CFI Older Adults sup-
plementary module. In revising the DSM-IV OCF into the DSM-5 CFI, the DSM-5
Cross-Cultural Issues Subgroup drew upon case studies underscoring clinician expe-
riences that the OCF could not be applied to older adults without significant modifi-
cations. The CFI approach encompasses a set of resources that may be particularly
useful to clinicians working with older adults, including the Older Adults supple-
mentary module, the CFI–Informant Version, and the Caregivers supplementary
module. We hope that clinicians continue to write reflectively on the costs and bene-
fits of implementing the CFI within their service settings. Such publications can help
us iteratively improve the cross-cultural mental health care of older patients.
KEY CLINICAL POINTS

• Cultural competence in work with older adults consists of exploring the unique
identities of patients, the relationship of these identities to clinical care, and cultural
attitudes in this developmental phase.
• Older adults may have medical conditions and neuropsychiatric disorders that sug-
gest a need for collateral history to complete a thorough cultural assessment.
• The core Cultural Formulation Interview (CFI), the CFI–Informant Version, and
supplementary modules can be used to conduct a thorough cultural assessment
of older adults.
Questions
1. Why is it important to understand cultural attitudes of aging in the care of old-
er adults?
2. How does the clinician’s cultural background or identity affect his or her atti-
tude toward aging and the needs of the older population?
3. What aspects of aging are addressed in the Older Adults supplementary

module?
4. What are some ethical concerns in using informants and caregivers to assess
the cultural needs of patients?
References
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Cult Gerontol 4(1):75–81, 1989 24389953
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Edmonson R: Cultural gerontology: valuing older people, in Old Age in Europe: A Textbook of
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Whose Hands? Washington, DC, National Academies Press, 2012
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treatment of late-life depression. Acad Med 81(2):171–175, 2006 16436580
Luborsky MR, LeBlanc IM: Cross-cultural perspectives on the concept of retirement: an ana-
lytic redefinition. J Cross Cult Gerontol 18(4):251–271, 2003 14654730
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Suggested Readings
J Am Geriatr Soc 58:2191–2196, 2010. This article on revising the OCF for use with older
adults helped to revise the CFI in focusing on the needs of older adults.
American Association for Geriatric Psychiatry: Geriatric Core Competencies. McLean, VA, Amer-
ican Association for Geriatric Psychiatry, 2011. Available at: http://www.aagponline.org/
index.php?src=gendocs&ref=GeriatricCoreCompetencies&category=Education. Accessed
September 15, 2014.
Immigrants and Refugees
Mental health and adjustment of world refugee populations fleeing war and
persecution has been a core area of study and practice in cultural psychiatry over the
past several decades. The effects of premigration and migration trauma have been
well described (Hollifield et al. 2006), along with the challenges of postmigration ad-
justment and acculturation (Finch and Vega 2003). Clinicians need practical tools to
assess the mental health and functioning in these families and communities. The Cul-
tural Formulation Interview (CFI) Immigrants and Refugees supplementary module
allows clinicians to optimize assessment and treatment of these populations. This
supplementary module can guide clinicians to efficiently recognize factors that influ-
ence mental health, such as premigration difficulties, exposure to violence and perse-
cution, the historical time frame of migration, migration-related losses and
challenges, continued ties to the country of origin, resettlement and life in the new
country, and future expectations. After a discussion of the module, we explore some
of the challenges involved in the assessment of refugees and immigrants.

The Immigrants and Refugees supplementary module consists of 18 questions di-
vided into seven sections (see Appendix C in this handbook). We discuss each of the
sections, describing how exploration of these domains can enhance the clinician’s
ability to perform an effective assessment.
Background Information
Questions 1–4 obtain information on the patient’s background and that of his or her en-
tourage, including the reasons for migrating. A migrant is a person who relocates from a
familiar sociocultural environment to an unfamiliar one (Westermeyer 1989b). This relo-
cation may involve minimal geographical distance but represent a major sociocultural
separation from the past. Alternatively, an individual may migrate thousands of miles but
173
settle in a highly familiar sociocultural setting. Migration can be intranational or interna-

tional. Refugees make up a special subgroup of migrants. Typically, they have involun-
tarily fled their homeland because of political, religious, or ethnic prejudice, pogroms,
imprisonment, or armed conflict against the group to which they belong.
The individual’s age at migration sets the stage for the subsequent story. The cli-
nician can then proceed with age-appropriate topics, from location and conditions of
birth, to family constellation, to education and socialization in the culture of origin or
in the culture of relocation. If migration was motivated by economics, the patient’s
motivations and expectations should receive attention. If war or revolution predated
migration, trauma and loss should be covered. If political, religious, or ethnic po-
groms precipitated flight, their nature and personal effects should be plumbed (De
Jesús-Rentas et al. 2010).
Understanding the patient’s personal motivation for and expectations of migra-
tion is critical. Voluntary and involuntary migration can present differing clinical prob-
lems (Berry et al. 1987). Voluntary migrants may include students, guest workers,
vacationers, entrepreneurs, and others. Typically, they travel alone or in family
groups, although they may also affiliate with an expatriate group from the same
country or region. They can return to their original country or community if they
wish. Involuntary migrants might have their land taken from them so that it can be
used for some social purpose (e.g., creating a water reservoir, building a road); they
might remain in the same country. Involuntary migrants who leave their country of
origin tend to be refugees. Unlike voluntary migrants, they are likely to migrate in
large groups, perhaps as large as thousands or hundreds of thousands of people, and
they often cannot return to the country of origin. International adoptees can be con-
sidered involuntary migrants who relocate alone or in small groups. Temporary or per-
manent migrations may occur. Temporary purposes consist of vacations, training,
education, or temporary work. Permanent migrations include relocating to become a
citizen of a new country, to marry a citizen of another country, to be adopted, or to
start a new career. From a mental health perspective, each of these age-related factors
contains specific liabilities and advantages.
Differences between “life before” and “life after” migration can precipitate disor-
der or undermine adjustment. For example, a subservient wife may become the new
family breadwinner; a member failing to acculturate in a family whose other mem-
bers are acculturating may become marginalized within the family; a family accus-
tomed to servants may not be able to afford them; and students trained for rote
memorization may have trouble with problem solving, group formats, informatics,
statistics, or writing skills. Unfamiliar climate, food, dress, housing, laws, and lan-
guage may be welcome to one migrant but anathema to another.
Premigration Difficulties
Questions 5 and 6 cover premigration difficulties. Determinants of mental health for
refugees depend on both past trauma and postmigration stress (Silove and Ekblad
2002). Violence is a worldwide problem and takes multiple forms. State-sponsored
military actions, civil wars, and ethnic cleansing have resulted in the deaths and
Supplementary Module 11: Immigrants and Refugees 175
wounding of thousands of people. Random, unpredictable paramilitary actions and

religious conflict have added to the list of victims of violence. In addition, state-
sponsored oppression and torture have affected millions of people. Some migrant
patients have committed crimes prior to migration, the consequences of which may
follow them (e.g., engaging in torture, terrorist activities, misrepresentation, drug
smuggling).
The Immigrants and Refugees supplementary module can illuminate past traumatic
experiences that have significant effects on individuals and families. The pervasive effects
of hardship, persecution, and profound losses include not only trauma but also the disin-
tegration of families and communities, the destruction of economic infrastructures, and
the imposition of fear into daily life (Desjarlais et al. 1995; Summerfield 2000). Succes-
sive threats and human rights violations compound each other to challenge multiple
adaptive systems at both individual and communal levels (Silove 1999).
Migration-Related Losses and Challenges

Questions 7–10 elicit information about migration-related losses and challenges.
Common losses include separation from family and close friends and loss of a house,
a job, or one’s social network. Loss of a sense of control over the environment and so-
cial rules in a well-known culture may also occur. The following case of an Iranian
woman who migrated to North America illustrates the challenges of separation, loss,
and trauma experienced by many refugees and immigrants.
Case Vignette
“Am I bad woman? Doctor, do you think I am a bad woman?” Afsar asks her psychiatrist.
She has been in Canada for 2 years as a refugee and has been dealing with severe depres-
sion. She was able to leave Iran when her husband was imprisoned for political reasons.
From time to time, her parents are able to send her news about him. Over the past 2 years,
every time she has heard about her husband, she has learned that his health continued to
deteriorate. Recently, Afsar heard that he is in a hospital and is not expected to improve; her
parents were told that there is no hope. Afsar was able to reach her husband at the hospital
on his birthday (after more than a year of no contact), but he did not even recognize her on
the phone. She has been trying to move forward with her own treatment and with her life
in Canada. Afsar attends English classes, and her ability to communicate in English has im-
proved considerably, so much so that an interpreter is no longer needed. However, every
time she receives news about her husband, her depression worsens. Her reason to keep
fighting is to be strong for her daughters. She has two daughters in Iran with whom she has
daily contact through the Internet. Afsar wishes to be well one day because her daughters
need her and she wants to be able to support them. She feels safe in Canada and happy she
was able to escape, but at the same time she feels guilty for leaving her family behind.
Video 9 depicts the challenges of separation from family and functioning in a new
social network after voluntary migration.
Video Illustration 9: A small town, which is why I’m here (4:39)
In this video (highlighted in “Aspects of Cultural Identity Related to National,

Ethnic, and Racial Background; Language; and Migration” also), a psychiatrist
conducts an interview with a middle-aged Puerto Rican man who suffers from
anxiety symptoms at work after his mother, who lives in Puerto Rico, has a
stroke. The aim of the National, Ethnic, and Racial Background portion of the
Cultural Identity supplementary module is to assess how a person’s national,
ethnic, and racial background affects his or her sense of self and his or her place
in society and how these aspects of identity influence behavior. In this video,
the clinician frames the purpose of the interview. This is an important part of
any supplementary module, because it clarifies for the patient how the subse-
quent questions relate to the patient’s reason for seeking help. In this case, the
interviewer emphasizes that he wants to understand whether the patient’s cul-
tural identity influences his mental health problems and his expectations of
care. The initial questions immediately reveal the reason for seeking help. The
patient is experiencing substantial anxiety because his mother is in Puerto Rico
in a town with limited access to the tertiary medical care she needs for her
stroke. He feels pressure to return to the island to provide the care she needs,
as seems to be expected of any good Puerto Rican son. In fact, if he does not go,
his family might think less of him and perhaps even repudiate him to some ex-
tent. The conflict stems from the fact that his sense of himself is connected to
being the kind of person who takes risks to become successful, including mi-
grating to the United States for a better future. To complicate matters further,
he fears that he could lose his job if he responds to what he and his community
in Puerto Rico interpret as his filial duty. He appears puzzled by the reaction of
his employers, who are unwilling to grant him leave from work to travel. He
says, “At work they...kinda don’t get this thing with family. I don’t quite un-
derstand how it works over here, but it’s almost like family isn’t important, like
you’re supposed to go working anyway, you can’t take any time off.” His cur-
rent predicament highlights the cultural differences between his new environ-
ment and key aspects of his identity, and this conflict appears to be heightening
his anxiety.
Information on a patient’s cultural identity can help clarify perspective on
health, illness, and the mental health system. The way an individual represents
himself to others, how he feels about his position in society, and how this re-
lates to his mental health problems is useful information for the clinician. Start-
ing from the information obtained in the video, the interviewer can proceed to
elicit additional details. For example, the interviewer could obtain more infor-
mation on the patient’s role in his family. The clinician could ask if the patient
is the eldest son, who is thought to have a special responsibility for his mother,
or how his family reacted to his migration and to his drive to succeed, which
may put extra pressure on him that could contribute to his symptoms. To help
with the current situation at work, the clinician could inquire whether he has
felt misunderstood there in other situations, whether there are other Puerto Ri-
can coworkers, whether they have experienced the same kind of misunder-
standings, and whether he is afraid to be discriminated against as a result of
his ethnicity if he asks for unpaid leave.
Ongoing Relationship With Country of Origin

Some migrants keep strong connections with their country of origin, as examined in
questions 11 and 12. Many are responsible for supporting family left behind. One or
two parents may leave for better job opportunities to be able to send money back
home to support their children, left in the care of family members. The Internet has
facilitated contact and enables migrants to talk to and see family and friends, some-
times daily. Some migrants keep strong business connections with their country, or
they may be working for a group or institution from their country of origin. These re-
lationships may impede the acculturation process, reinforcing a strong connection
with the homeland.
Resettlement and New Life

Challenges associated with resettlement are explored in module questions 13–15. The
arrival in a new country can present difficult challenges, such as obtaining visas, cit-
izenship, or refugee status. This complex process can be a huge obstacle for someone
who has just arrived, is not yet fluent in the new language, and has no source of in-
come.
Acculturating to a new country lasts throughout a lifetime. Age at migration can
influence the extent to which a migrant acculturates to a new society. Other things be-
ing equal, younger age favors more thorough acculturation. Children’s greater profi-
ciency with the host country’s language frequently leads to the reversal of traditional
generational roles, as the children become the communication facilitators and culture
brokers between the family and the majority society.
For migrants of an advanced age, acculturation may be minimal or superficial. Af-
ter migration, elderly refugees may live with a diminished status both within families
and in the society at large because of a lack of language proficiency, little or no formal
education, and no relevant work. The willingness of the migrant to be assimilated and
the willingness of the receiving culture to assimilate the migrant can also affect this
process in deep and lasting ways.
Acculturation failure refers to the absence of reasonably functional acculturation,
given the age of the migrant and the mutual assimilation processes of the migrating
and receiving cultures (Westermeyer 1989b). Refugee children and adults may have
suffered conditions—bullet, shrapnel, or blast wounds to the brain; malnutrition; in-
fectious disease; torture; and other conditions—that impede acculturation by limiting
the capacity to acquire new knowledge, skills, and attitudes (Ahearn and Athey
1991). Elderly refugees may lack the motivation or cognitive capacity to acquire a new
language, as well as the innumerable skills and requisite knowledge to function in a
new culture. Young and middle-aged migrants may have to alter life plans and
change careers, while concurrently caring for their children and aging parents.
Successful acculturation requires affiliation with individuals and groups from the
receiving culture. Through these relationships, migrants learn the new culture. This
learning involves decisions regarding what new norms and skills to acquire and what
to leave behind. Continued contact with expatriate friends and relatives, who have
been undergoing the same process, serves critical functions in processing the changes,
exploring moral and identity issues, and garnering support (Chance 1965; Leung and
Boehnlein 2005).
Relationship With the Clinical Problem

Questions 16 and 17 explore the links between the migration experience, the current
situation in the new country, and the clinical problem being assessed. Chronology of
migration can affect the type of psychiatric condition that develops. Adjustment dis-
orders usually occur within several months of relocation, but they can also occur
years later if acculturation is delayed. Anxiety and mood disorders tend to appear
within the first years of relocation, whereas substance use disorders typically appear
several years or more after relocation (Krupinski 1967). Psychosis may occur at any
time in relation to migration. Paranoid symptoms and disorders occur more often in
migrant patients than in persons in their native-born community (Kendler 1982). Be-
cause paranoid symptoms, such as mistrust or projected hostility, can occur with
most conditions, clinicians must beware of overdiagnosing paranoid disorders in mi-
grants. Paranoid symptoms tend to abate gradually over the first decade following re-
location (Westermeyer 1989a). However, paranoid disorders, like other psychoses,
can appear at any time following relocation. Secondary relocations following migra-
tion may be salutary but also can complicate adjustment if resources are lost and ad-
justment challenges remain unchanged.
Future Expectations
Despite the difficulties involved in migration, migrants often view it as a new begin-
ning and have hopes and plans for the future. Including question 18 at the end of the
interview brings perspective to the situation—that as hard as migration may be, it can
be seen as a transition to a better future. Successful resettlement can produce many
personal and social gains. The individual matures and gains greater appreciation of
the self and others. Enhanced competence may pervade many aspects of daily life.
Challenges in Assessment
Various challenges are involved in the assessment of immigrants and refugees. Clari-
fying the reasons and context for an initial assessment is usually helpful. Collaboration
with interpreters is critical for both migrants and clinicians. For both partners in the
clinical dyad, the addition of one person triples the interpersonal complexity: from pa-
tient-clinician to interpreter-patient, interpreter-clinician, and patient-clinician
(Mirdal et al. 2012; Westermeyer 1990). Clinicians must appreciate the challenge of
translating culturally embedded emotional and symbolic terms (e.g., anxiety, depres-
sion, morale) contrasted with terms describing universal physical or physiological ex-
periences (e.g., tachycardia, diarrhea, nightmares). Inquiry into less-than-universal
experiences (e.g., delusions, hallucinations, fugue, delirium) requires special phrasing
for each language and dialect. Some cultures require that a family member be present
or nearby, especially if the patient-clinician dyad differs by gender.
Cultural transference can intrude, for good or ill (Comas-Díaz and Jacobsen 1991).
The patient may overvalue the clinician’s culture, leading to unrealistic expectations,
or the patient’s culture may have an unsavory political history or class conflict with
the clinician’s presumed ethnic group, creating a barrier to trust. Clinicians may like-
wise manifest cultural countertransference, which can impede and/or augment the
clinician’s commitment to the migrant patient. Useful clinician attributes in assessing
and treating migrants include curiosity, open-mindedness, flexibility, creativity, ac-
ceptance, and previous cross-cultural experience in adapting to another society. The
questions in the Patient-Clinician Relationship supplementary module may help the
clinician explore this important aspect of care.
Obstacles to assessing distress and psychiatric disorders across cultural groups in-
clude language barriers; variations in cognitive and emotional schemata, social tradi-
tions, and cultural beliefs; and continued change in these variables as acculturation
occurs (Lu et al. 1995). Efficiently and comprehensively integrating social science and
psychiatric perspectives is essential in interviewing refugees and immigrants so that
assessment is accurate and treatment is effective. For example, understanding how a
particular cultural group interprets the symptoms of an illness and its appropriate
treatment can facilitate adherence with appropriate treatment after migration (Har-
wood 1981). A cross-cultural interview, while maintaining a systems perspective, also
should not lose sight of the uniqueness of each individual or family who has migrated
in search of safety, security, and a better life.
Conclusion
The CFI, including the Immigrants and Refugees supplementary module, provides
access to clinically relevant information useful in the care of migrants. Assessment us-
ing these tools reassures patients by including salient queries critical to understand-
ing migrants and their dilemmas. The CFI informs the clinician’s assessment, setting
a realistic foundation for treatment planning. It enables clinicians to make recommen-
dations, undertake negotiations, promote acceptance and adherence, and achieve an
optimal clinical outcome.
KEY CLINICAL POINTS

• Important factors that influence mental health among immigrants and refugees in-
clude premigration difficulties, exposure to violence and persecution, the historical
time frame of migration, migration-related losses and challenges, continued ties to
the country of origin, resettlement and life in the new country, and future expecta-
tions.
• A cross-cultural assessment, while maintaining a systems perspective, should not
lose sight of the uniqueness of each individual and family.
Questions
1. What are the most common challenges that immigrants and refugees encoun-
ter after migration?
2. What is the relevance of premigration challenges for postmigration adjust-

ment?
3. What are some frequent losses experienced by refugees and immigrants, re-
gardless of country of origin?
4. What are some factors that influence successful or unsuccessful acculturation?
5. What are frequent obstacles for clinicians in being able to accurately and effi-
ciently assess immigrant and refugee mental health status?
References
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Johns Hopkins University Press, 1991
Berry JW, Kim V, Minde T, et al: Comparative studies of acculturative stress. Int Migr Rev
21:491–511, 1987
Chance NA: Acculturation, self-identification and personality adjustment. Am Anthropol
67:372–393, 1965
De Jesús-Rentas G, Boehnlein J, Sparr L: Central American victims of gang violence as asylum
seekers: the role of the forensic expert. J Am Acad Psychiatry Law 38(4):490–498, 2010
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Desjarlais RL, Eisenberg L, Good B, et al: World Mental Health: Problems and Priorities in Low-
Income Countries. New York, Oxford University Press, 1995
Finch BK, Vega WA: Acculturation stress, social support, and self-rated health among Latinos
in California. J Immigr Health 5(3):109–117, 2003 14512765
Harwood A: Ethnicity and Medical Care. Cambridge, MA, Harvard University Press, 1981
Hollifield M, Warner TD, Jenkins J, et al: Assessing war trauma in refugees: properties of the
Comprehensive Trauma Inventory-104. J Trauma Stress 19(4):527–540, 2006 16929508
Kendler KS: Demography of paranoid psychosis (delusional disorder): a review and compari-
son with schizophrenia and affective illness. Arch Gen Psychiatry 39(8):890–902, 1982
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Leung PK, Boehnlein JK: Vietnamese families, in Ethnicity and Family Therapy, 3rd Edition. Ed-
ited by McGoldrick M, Giordano J, Garcia-Preto N. New York, Guilford, 2005 pp 363–373
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als, in American Psychiatric Press Review of Psychiatry, Vol 14. Edited by Oldham JM,
Riba MB. Washington, DC, American Psychiatric Press, 1995 pp 477–510
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interpreters: three perspectives on psychological treatment. Psychol Psychother 85(4):436–
455, 2012 23080532
Silove D: The psychosocial effects of torture, mass human rights violations, and refugee
trauma: toward an integrated conceptual framework. J Nerv Ment Dis 187(4):200–207,
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Suggested Readings
Birman D, Chan WY: Screening and Assessing Immigrant and Refugee Youth in School-Based
Mental Health Programs. Washington, DC, Center for Health and Health Care in Schools,
2008. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2008/
rwjf29520. Accessed February 16, 2015.
Centers for Disease Control and Prevention: Immigrant and Refugee Health, 2013. Available at:
http://www.cdc.gov/immigrantrefugeehealth/. Accessed February 16, 2015.
U.S. Citizenship and Immigration Services: Refugees & Asylum, 2011. Available at: http://
www.uscis.gov/humanitarian/refugees-asylum. Accessed February 16, 2015.
Caregivers
Ladson Hinton, M.D.
Rita Hargrave, M.D.
Iqbal Ahmed, M.D.
Caregivers often play a central role in the lives of persons with mental ill-
ness. Caregivers perform a diverse set of roles, including providing emotional sup-
port and helping with decision making, participating in clinic visits, and helping with
patient adherence to mental health treatment. For clinicians to most effectively engage,
mobilize, and support informal helpers (i.e., immediate family, extended family, friends),
they must understand how culture shapes the meanings, values, and activities associated
with the caregiving role. For example, a Vietnamese caregiver for a patient with dementia
in the United States may draw on concepts from Buddhism and Catholicism (e.g., karma,
God’s will) to make sense of her relative’s dementia, to experience the caregiving role as
an act of sacrifice and compassion, and to cope with her own personal suffering (Hinton
et al. 2008). Awareness of these cultural orientations to caregiving would help the clini-
cian support the caregiver in a culturally congruent fashion and understand her resigned
and accepting view of the illness and of treatment (often glossed over as “fatalism” by
health professionals). The Caregivers supplementary module of the DSM-5 (American
Psychiatric Association 2013) Cultural Formulation Interview (CFI) is a tool to assist cli-
nicians in the cultural assessment of caregiving, with the ultimate goal of promoting ac-
curate diagnosis and treatment that are both patient and family centered. In this
subchapter, we describe the rationale for the Caregivers module, summarize its contents,
and propose guidelines for its clinical use.

Mental illness is experienced, expressed, and responded to within an interpersonal
context that often includes family members, extended family, and friends or neigh-
The views expressed in this publication are those of the authors and do not reflect the official
policy or position of the Department of the Army, Department of Defense, or the U.S. govern-
ment.
182
Supplementary Module 12: Caregivers 183
bors (i.e., informal social networks). In many situations, members of the patient’s in-
formal network will be sources of emotional, instrumental, and material support in
dealing with psychiatric symptoms, treatment, and recovery. Assessing caregiver
perspectives and roles in the lives of persons with mental illness and, when appropri-
ate, engaging them in the treatment process can be very important.
Caregivers can, for example, extend and augment mental health treatment in power-
ful ways, such as by providing collateral information, helping with treatment adherence,
and monitoring psychiatric symptoms and medication side effects (Lefley 1996). Because
mental health problems can take a substantial emotional, social, and financial toll on care-
givers, clinicians need to assess the caregiver levels of burden and to offer support so that
they do not “burn out” or suffer adverse health and/or mental health outcomes. Family
caregivers of persons with dementia, for example, are at increased risk for depression and
psychological distress, adverse physical health outcomes, and even cognitive decline (Liu
and Gallagher-Thompson 2009; Schulz and Beach 1999; Vitaliano et al. 2003). Al-
though caregivers experience considerable stress, they also report positive feelings about
caregiving, including a sense of family togetherness, reciprocity, and satisfaction about
helping others (Zarit 2012). When clinicians assess caregiving dynamics and roles, they
are in a better position to intervene when caregivers negatively impact patients’ mental
health treatment (e.g., by providing depression psychoeducation when family members
and friends discourage treatment or view depression as a moral failing rather than an ill-
ness). Clinicians need to keep in mind that individual caregivers may sometimes be a
“double-edged sword” in the sense that they are acting in ways that both promote and
hinder mental health care (Hinton et al. 2014).
How members of a patient’s social network interpret and respond to mental
health problems reflects their own cultural conceptions of health and illness, social
role expectations, styles and norms of verbal and nonverbal communication, and ori-
entations to health and mental health care (Knight and Sayegh 2010). These reactions
matter for the course of illness. For example, expressed emotion, including both crit-
ical comments and limited expressions of warmth, influences the likelihood of rehos-
pitalization among patients with schizophrenia (Jenkins and Karno 1992; López et al.
2004). Knowing how best to support caregivers requires understanding the role of
culture in shaping caregiving-related roles, values, and ethics (Hinton et al. 1999). Al-
though these cultural orientations are often shared by the caregiver and patient, in-
creasingly in pluralistic and multicultural settings there may also be important
differences within informal social networks.
Caregiving systems are often complex in structure and dynamics. At any given
point in time, for example, a person with mental illness may rely on more than one
person for help and support in dealing with his or her mental health problem. For ex-
ample, a young Latina with schizophrenia may be accompanied to mental health vis-
its by her sister but rely on her elderly mother for day-to-day help at home with
medication adherence and on her husband for assistance with decision making. Pat-
terns of caregiving may change over time, resulting in changes in caregiving roles and
levels of involvement. Awareness of the distribution of different aspects of caregiv-
ing—emotional, instrumental, and material—will help clinicians navigate these in-
formal systems of support.

The Caregivers supplementary module (provided in Appendix C in this handbook) al-
lows clinicians to explore important psychosocial issues that affect caregivers, such as
their willingness to assume and accept the role of care provider, their reactions to their
perceived obligation or choice to provide care, and their preferences for how formal ser-
vices should be organized and delivered (Family Care Alliance 2006.). In contrast to the
CFI–Informant Version (Appendix B in this handbook), which focuses on a caregiver’s
views about the patient’s problem, the questions in the Caregivers supplementary mod-
ule permit more specific exploration of the type of support the caregiver provides and the
associated meanings, motivations, challenges, and rewards associated with this support.
The Caregivers module emphasizes four domains of assessment. The initial sec-
tion of the module (questions 1 and 2) allows the clinician to better understand the
nature and history of the caregiving relationship, including its duration and the con-
nection of the caregiver to the patient (e.g., immediate family, extended family or non-
familial support, paid or unpaid caregiver). Questions 3–8 focus on caregiving
activities and cultural perceptions of caregiving; the respondent is asked to describe
the nature and extent of the assistance he or she provides to the care recipient and to
identify the positive and challenging aspects of the caregiving relationship. This sec-
ond section of the module also encourages the respondent to articulate how cultural
traditions and practices may influence his or her approach to caregiving. The care-
giver is asked to assess whether his or her current activities are consistent with or at
odds with the role expectations of most caregivers in the community. The information
in this section can highlight potential sources of care-related strain. The third section
(questions 9–11) focuses on the social context of caregiving. The caregiver is encour-
aged to outline his or her current coping strategies for managing the care recipient
and to describe the extent and adequacy of support and assistance that he or she re-
ceives from family members, friends, or neighbors. The module concludes with ques-
tions 12–14, which explore the caregiver’s expectations of the mental health system
and his or her caregiving preferences. The module may be used in its entirety, or the
clinician may select specific questions to include in the assessment.

The person-centered process of administering the CFI–Informant Version and the
Caregivers supplementary module, as well as the collaborative dialogue between the
care recipient, health practitioner, and caregiver, is intended to enhance the cultural
validity of the assessment process, facilitate treatment planning, and promote the en-
gagement and satisfaction of the patient, his or her caregiver, and the rest of the sup-
port network. The information obtained from the module and the CFI–Informant
Version is complementary and should be integrated with other clinical material to
form the basis of a collaborative plan that includes attention to caregiver issues and
is comprehensive and culturally relevant.
Prior to administering the Caregivers module, clinicians must decide whether,
when, and how to engage informal caregivers in the diagnostic and treatment pro-
cess. To inform these decisions, clinicians should consider 1) the availability of care-
givers in the patient’s life, 2) the patient’s preferences for involvement of an informal
caregiver in clinical care, and 3) the real or potential adverse effects of informal care-
giver involvement in clinical care. We briefly discuss each of these considerations.
First, the clinician must determine whether the patient is relying on a caregiver for
help in managing his or her mental health problem. In some situations, it may be
quite clear that the patient relies heavily on a family member or friend for assistance.
A patient may, for example, ask that a family member or friend accompanying him or
her to the clinic be included in the clinical interview. In other situations, the clinician
may first become aware of the role of informal helpers through the core CFI. For ex-
ample, a patient with schizophrenia may mention that he or she lives with family
members who help with medications and who often accompany him or her to the
clinic.
Second, the clinician should assess whether the patient prefers to have an informal
helper involved in the clinical encounter. The clinician should initiate a discussion
with the patient about the involvement of a caregiver both as a source of collateral in-
formation on the patient’s situation and in terms of the caregiver’s own views and ex-
periences as a provider of care. This consultation with the patient may help the
clinician respect his or her desire for autonomy and privacy and explore the reasons
why the patient may not want family to be involved. This discussion may illuminate,
for example, sources of family friction or conflict. It is important to remember that
family involvement is not all or nothing; it is possible for family to be involved only
in certain aspects of the diagnosis or treatment process. With a flexible and open ap-
proach, clinicians are more likely to successfully navigate these social relationships to
benefit treatment while respecting the wishes of the patient.
Finally, the clinician needs to consider the possible adverse impact of family mem-
bers or other informal helpers on the patient’s mental health treatment. Family mem-
bers can impede treatment in a variety of ways, including discouraging initial care
seeking or adherence to treatment, criticizing the patient or expressing stigmatizing
views of mental illness, and disrupting communication during clinic visits. In the
most extreme cases, dysfunctional relationships with informal caregivers may actu-
ally trigger or amplify mental health symptoms. During the process of diagnostic as-
sessment, clinicians will want to evaluate the roles of family members, assess
potential pitfalls of family involvement, and identify clinical interventions to address
these issues in order to enhance care. For example, a psychoeducational intervention
may help family members view mental illness in less stigmatizing ways and improve
how they communicate with the patient. The recommendations of the Patient Out-
comes Research Team study of schizophrenia suggest that persons with this disorder
who have ongoing contact with their families, including relatives and significant oth-
ers, should be offered a family intervention. This intervention has been found to sig-
nificantly reduce rates of relapse and rehospitalization (Dixon et al. 2010).
The Caregivers supplementary module can be used in conjunction with other CFI
components, particularly the CFI–Informant Version. These two instruments are
quite complementary. Whereas the CFI–Informant Version assesses the informant’s
views on the patient’s illness and other aspects of the presented problem—essentially
gathering all of the core CFI information from the informant’s perspective—the Care-
givers module assesses the meaning and impact of caregiving itself. It is important,
however, for clinicians to recognize that most, but not all, informants will also be care-
givers.
The Caregivers module may be used during the diagnostic interview or later in
the course of treatment. For example, the clinician may become aware that a caregiver
is distressed and seek to better understand his or her experience and the impact of
caregiving on his or her well-being. Other supplementary modules may also elicit in-
formation to complement the Caregivers module, including the Social Network and
Psychosocial Stressors modules. The Social Network module helps the clinician
gather information about the patient’s broader social network, including caregivers.
This might be useful, for example, if the clinician is trying to identify family members
who are not engaged in caregiving but might be mobilized to assist with some aspect
of treatment. The Psychosocial Stressors module may be used to examine negative as-
pects of caregiving relationships, such as interpersonal conflicts with the caregiver.
Both of these modules are administered to the patient and may provide important
contextual information to guide the assessment of caregiving issues.
Like the core CFI, the Caregivers module encourages clinicians to use follow-up
or rephrased questions as needed to clarify the respondent’s answers. This module
was designed to be a practical and flexible guide to cultural assessment, an aid to the
elucidation of the respondent’s perspective on caregiving, and a tool to promote rap-
port building and collaboration between the caregiver and the clinician. The clinician
may choose to use all or only part of the module, depending on what components of
the instrument seem most relevant to clinical care. Also, the clinician may choose to
administer the module during the same visit as the core CFI or at subsequent visits,
depending on the clinical situation.
In situations with multiple family members or caregivers, pragmatic decisions
must be made about whom to interview based on patient preferences as well as care-
givers’ knowledge of the patient and the extent to which they are involved in day-
to-day caregiving activities. However, each caregiver may raise different important
cultural issues affecting care. For example, caregivers from apparently similar cul-
tural backgrounds may be acculturated to the larger culture to varying degrees in a
racial/ethnic minority or immigrant family, especially if they are from different gen-
erations, as presented in the vignettes below.
Caregiver assessment can be beneficial to caregivers at any stage of treatment. The
CFI Caregivers module, like other caregiver assessment tools, should be used in the
early stages of treatment to engage the caregiver as an active participant in the treat-
ment planning process and to identify unmet psychosocial and service needs (Family
Care Alliance 2006.). Some authors conceptualize caregiver assessment as an ongoing
process and recommend periodic reassessment of family helpers. Family caregivers
are frequently engaged in the process for several years, and their views and experi-
ences may be affected by changes in the care recipient’s and a caregiver’s health and
level of functioning, as well as family economic resources. Regular collaborative dia-
logues between clinicians and caregivers, guided by instruments such as the CFI, may
identify critical areas of the treatment plan that require modification, highlight unmet
needs of the caregiver and his or her support network, and assist in the evaluation of
the effectiveness of the existing treatment plan (Family Care Alliance 2006.). The fol-
lowing vignettes illustrate approaches that the clinician may find useful in working
with caregivers.
Case Vignette 1
Beatrice is a 78-year-old African American woman suffering from Alzheimer’s disease,
hypertension, and diabetes mellitus who was admitted to the hospital for delirium and
confusion after she sustained a fall at her home. Beatrice’s husband had been her pri-
mary caregiver until his death 6 months earlier. Her son John flew into town after she
telephoned and told him, in a moaning voice, that the nurses were abusing her, giving
her the wrong medications, and trying to poison her. John was irritable and confronta-
tional with nursing staff and demanded to speak with the hospital administrator to se-
cure better care for his mother. Even though he lived in another state 1,000 miles away,
as the youngest of four children, he had been raised to accept his role in the family as
his mother’s primary caregiver. He resisted asking his siblings to help by increasing
their participation in their mother’s care. Like his mother, John believed that his siblings
were not capable or strong enough to be effective advocates for her; he alone felt he
could be responsible for her care.
In this situation, the Caregivers supplementary module could help clarify the ex-
tent and availability of the caregiving network and the adequacy of the primary care-
giver’s coping strategies for managing the care recipient. Resulting recommendations
might include psychoeducation of the caregiver on the needs of older adults with
cognitive decline and joint development of a strategy to increase collaboration be-
tween the caregiver, his family, the patient, and the medical staff.
Case Vignette 2
An Asian Indian family that had immigrated to the United States decided to bring the
husband’s mother from India to help diagnose growing signs of cognitive impairment.
The patient was depressed, claiming that her daughter-in-law—the main caregiver—
was not sufficiently respectful and deferential toward her. The daughter-in-law, a col-
lege graduate, had been raised in a fairly westernized family in a large Indian city,
whereas her husband, an engineer, had been raised in a traditional family in a small In-
dian town. The daughter-in-law shared the family view that she had a filial responsi-
bility to care for her husband’s mother, but she felt that the expectations from both her
husband and her mother-in-law were unreasonable. This led her to feel resentful as well
as guilty about these feelings; she felt that she should be more assertive about her own
“psychological needs.” The couple’s two children had been raised in the United States
and were in high school. Although they occasionally helped their mother in caregiving
activities, they could not understand why a professional caregiver could not be brought
in to help. The husband felt that his job consumed his time and that, in any case, it was
really his wife’s role to take care of his mother, as had been the case in the community
in which he was raised. The clashing family views led to marital conflict. The couple
had a handful of Indian friends but no friends from the larger community; they were
ashamed to discuss their problems with their Indian friends and decided to seek help
from a psychiatrist of Indian background because they felt he might understand the
cultural issues involved.
In this situation, the core CFI, the CFI–Informant Version, and the Caregivers sup-
plementary module could help the clinician appreciate and disentangle the cultural
perspectives of the patient, the primary caregiver (the daughter-in-law), and the sec-
ondary caregivers (the son and grandchildren). A culturally appropriate intervention
would need to be formulated to address the family conflict, which is driven at least
in part by cultural expectations about caregiving, and the nature of interpersonal re-
lationships, including intergenerational expectations.
Conclusion
Family involvement in mental health care is widely recognized as a critical element
for strengthening mental health interventions and services (Sederer and Sharfstein
2014). The Caregivers supplementary module and the CFI–Informant Version can
help clinicians better understand the cultural dimensions of caregiving and connect
with the experience of informal caregivers, including immediate family, extended
family, and nonfamily helpers. Armed with this knowledge, clinicians will be better
positioned to mobilize these social relationships to advance care, mitigate any nega-
tive effects of these relationships, and support and strengthen the caregiving systems.
KEY CLINICAL POINTS

• Care of patients often occurs in a larger social context, including informal caregiv-
ers such as family members.
• Cultural factors impact the perception of the illness, the meaning and value of care-
giving, the relationship between the patient and the caregiver, and the availability
of social support, all of which can affect caregiver burden.
• By assisting in the evaluation of these cultural factors, the Cultural Formulation In-
terview can help enhance the quality of patient care and reduce caregiver burden,
leading to the use of culturally informed approaches.
Questions
1. What four domains of assessment does the CFI Caregivers supplementary
module emphasize?
2. Prior to administering the Caregivers supplementary module, what issues do

clinicians need to consider to guide decisions about whether, when, and how
to engage informal caregivers in the diagnostic and treatment process?
3. What other supplementary modules may also elicit information to comple-

ment the Caregivers module?
4. How does the Caregivers supplementary module differ from the CFI–Informant
Version?
5. To best support caregivers requires understanding the role in culture in what

aspects of caregiving?
References
Dixon LB, Dickerson F, Bellack AS, et al: The 2009 schizophrenia PORT psychosocial treatment
recommendations and summary statements. Schizophr Bull 36(1):48–70, 2010 19955389
Family Care Alliance: Caregiver Assessment: Principles, Guidelines and Strategies for Change.
Report From a National Consensus Development Conference, Vol 1. San Francisco, CA,
Family Care Alliance, 2006. Available at: https://www.caregiver.org/national-consensus-
report-caregiver-assessment-volumes-1-2. Accessed May 14, 2014.
Hinton L, Apesoa-Varano EC, Unützer J, et al: A descriptive qualitative study of the roles of
family members in older men’s depression treatment from the perspectives of older men
and primary care providers. Int J Geriatr Psychiatry August 11, 2014 [Epub ahead of print]
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and family dementia caregiving. Cult Med Psychiatry 23(4):403–413, 1999 10647942
Jenkins JH, Karno M: The meaning of expressed emotion: theoretical issues raised by cross-
cultural research. Am J Psychiatry 149(1):9–21, 1992 1728192
Knight BG, Sayegh P: Cultural values and caregiving: the updated sociocultural stress and cop-
ing model. J Gerontol B Psychol Sci Soc Sci 65B(1):5–13, 2010 19934166
Lefley HP: Family Caregiving in Mental Illness. Thousand Oaks, CA, Sage Publications, 1996
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Aging Families and Caregiving. Edited by Qualls SH, Zarit SH. Hoboken, NJ, Wiley, 2009,
pp 85–112
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of schizophrenia: family warmth matters. J Abnorm Psychol 113(3):428–439, 2004 15311988
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Ahmed I, Kramer E (eds): Ethnic Minority Elderly Curriculum. Arlington, VA, American Psy-
chiatric Association, 2014. Available at: http://www.psychiatry.org/practice/professional-
interests/diversity/diversity-resources. Accessed May 15, 2014.
Family Care Alliance: Caregiver Assessment: Principles, Guidelines and Strategies for
Change. Report From a National Consensus Development Conference, Vols 1 and 2. San
Francisco, CA, Family Care Alliance, 2006. Available at: https://www.caregiver.org/
national-consensus-report-caregiver-assessment-volumes-1-2. Accessed May 15, 2014.

Kleinman A: From illness as culture to caregiving as moral experience. N Engl J Med 368:1376–
1377, 2013
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Yeo G, Gallagher-Thompson D: Ethnicity and the Dementias, 2nd Edition. New York, Rout-
ledge, Taylor and Francis Group, 2006
CHAPTER 4
Clinical Implementation of
the Cultural Formulation
Interview
Planning and Assessment

This chapter addresses implementation of the DSM-5 (American Psychiatric

Association 2013) Cultural Formulation Interview (CFI) within clinical practice. Im-
plementation has been defined as “the process of putting to use or integrating evi-
dence-based interventions within a setting,” and a formal implementation strategy has
been defined as “the systematic processes, activities, and resources that are used to
integrate interventions into usual settings” (Rabin and Brownson 2012, pp. 26–27).
My colleagues and I have made the case elsewhere that the CFI is an intervention in
development (Aggarwal et al. 2014) if we define interventions as purposive change
strategies that target malleable risk factors to produce positive outcomes (Fraser and
Galinsky 2010). In the case of the CFI, clinicians are encouraged to target the mallea-
ble risk factors of misdiagnosis, treatment disengagement, and patient dissatisfaction
through change strategies of open-ended questions on patient cultural views for di-
agnosis and treatment planning (American Psychiatric Association 2013).
Clinicians, administrators, and patients may wonder why an entire chapter on CFI
implementation is necessary. However, implementation often exposes the gap be-
tween researchers who develop interventions and the clinicians who use them. The
words of an article by scientists from the National Institutes of Health (NIH)—the
191
largest funder of biomedical research in the United States—remind readers that most
funding is spent on developing interventions rather than studying their use: “[F]or
each dollar spent in discovery, mere pennies are spent learning how interventions
known to be effective can be better disseminated” (Glasgow et al. 2012, p. 1274). In
fact, it takes 17 years to translate 14% of original research into interventions benefiting
patient care (Balas and Boren 2000). At various points throughout this time period,
granting priorities can change for research funding, publications may be rejected
from peer-reviewed journals, study findings may not be synthesized in textbooks and
practice guidelines, and interventions may not be disseminated even when they are
found to produce positive outcomes (Green et al. 2009). Keeping in mind that the CFI
represents a revision of the Outline for Cultural Formulation (OCF) that was origi-
nally published in DSM-IV (American Psychiatric Association 1994), one can appre-
ciate the length of time needed to develop an intervention through iterative revisions
and to achieve its eventual clinical implementation. In addition, overviews have dis-
cussed how clinical implementation is not simply a matter of “changing physician be-
havior.” For example, clinic administrators have named general barriers to
implementing interventions, such as the relevance of research interventions to real-
world practices, scattered information about interventions, difficulties in assessing
the quality of research evidence, training costs, provider resistance, and burdensome
workloads (Proctor et al. 2007). Work from the DSM-5 field trial revealed that health
providers report concerns about the unclear relevance of culture to treatment plan-
ning, training costs, and burdensome workloads as anticipated barriers to CFI use
(Aggarwal et al. 2013b; American Psychiatric Association 2013). For this reason, my
colleagues and I believe that a clear implementation strategy may help clinicians and
administrators bridge the research-practice gap in introducing the CFI within clinical
settings. The need to consider implementation issues from the beginning of develop-
ing an intervention around the CFI also falls in line with NIH funding priorities to
consider real-world needs in all steps of research (Carroll and Rounsaville 2003;
Nunes et al. 2010).
Aside from the research-practice gap, implementers of interventions also encoun-
ter structural barriers. The public health systems in many countries consist of a net-
work of government health agencies with laws, regulations, and priorities that vary
by administrative level (local, state, national), hindering implementation if there is
not systematic coordination (Stamatakis et al. 2012). Clinical experience with the OCF
has shown that implementation conforms to the exigencies of delivering care within
service constraints. For example, although there is worldwide interest in the OCF
(see Chapter 1, “Cultural Formulation Before DSM-5”), the lack of a coordinated im-
plementation strategy has led to different service models for OCF use. These service
models range from individual outpatient clinicians who ask patients direct questions
through OCF-based interviews to an entire cultural consultation service with over 50
culture and linguistic brokers at McGill University in Montreal, Quebec, Canada. No
data are available on whether the OCF has been used within private practice settings.
This fractured approach to OCF implementation has prevented generalizations
about clinician experience or standardization in the collection of research data
(Lewis-Fernández et al. 2014).
Planning and Assessment 193
This chapter, therefore, presents two possible CFI implementation strategies, one
for clinicians and one for organizational teams, the two groups of stakeholders ulti-
mately responsible for delivering culturally competent care to patients. Implementa-
tion research has grown over the past decade, with hundreds of researchers,
thousands of peer-reviewed publications, and billions of research dollars awarded to
such projects, many with competing theoretical backgrounds and implementation
strategies (Colditz 2012). One systematic review identified 68 discrete strategies to
plan, educate, finance, restructure, and evaluate the implementation of an interven-
tion within general health care settings (Powell et al. 2012), although only 11 studies
tested such strategies for mental health interventions (Powell et al. 2014). The tenet
that connects this disparate work throughout implementation science is a focus on
understanding what, why, and how interventions work in real-world clinical settings
with populations that will ultimately be affected (Peters et al. 2013). Given the real-
world emphasis in implementation work, the research climate has shifted from a pre-
vious model in which knowledge was seen to flow unidirectionally from researchers
to clinicians and administrators in favor of a more equitable model of exchange in
which all stakeholders contribute to and gain from collaboration (Proctor et al. 2009).
Evidence-based practices originating from researchers must be combined with prac-
tice-based evidence originating from clinicians to promote valid research, policy, and
practice (Chambers and Azrin 2013). Therefore, clinicians and administrators play
crucial roles in the adoption of any CFI implementation strategy. In keeping with the
multidisciplinary nature of implementation science, the goal in this chapter is not to
favor one perspective over another but rather to provide two such CFI implementa-
tion strategies for clinicians, administrators, and researchers and the organizational
teams they develop.
CFI Implementation Strategies

for Individuals and Teams
Implementation strategies have been called the how-to component of changing
health care practice when new interventions are introduced in clinical settings (Proc-
tor et al. 2013). Proctor et al. (2013) have proposed minimum standards for implemen-
tation strategies containing sufficient detail that interventions can be adopted in
practice, scientifically tested, and communicated clearly among clinicians, adminis-
trators, and researchers. This chapter uses these standards to envision a template for
implementing the CFI in diverse clinical settings. Clinical settings in which the CFI is
introduced may vary widely. Organizations have their own cultures and social struc-
tures, so administrators will need to assign personnel responsible for implementing
the CFI successfully. However, certain characteristics are common across all settings:
for example, it is the clinician who administers the CFI to the patient, not vice versa.
A crucial component in any implementation strategy is the extent to which the in-
tervention has been delivered with fidelity, as intended by the developers of the in-
tervention. If this fidelity is not evaluated, the impact of an intervention on health
outcomes cannot be known: any effects on outcomes can result from the science of the
intervention itself or from the strategy used to implement the intervention (Carroll et
al. 2007). For this reason, monitoring and evaluating fidelity to an implementation
strategy can point to both successful practices that should be retained and less suc-
cessful practices eligible for quality improvement. The process of implementation can
be divided into four phases: development, training, execution, and evaluation. Mea-
suring fidelity through each phase can help to troubleshoot barriers as they arise and
to identify unique threats to fidelity by phase. To assist measurement of CFI fidelity,
the Cultural Formulation Interview–Fidelity Instrument (CFI-FI) is introduced,
which has been tailored to the ultimate version of the core CFI included in DSM-5.
The development and psychometric properties of the CFI-FI followed rigorous re-
search standards, which are presented by Aggarwal et al. (2014). In this chapter, the
focus is on measuring CFI fidelity throughout the implementation phases of training,
execution, and evaluation. Fidelity should be measured effectively to assess desirable
performance and efficiently to prevent resource strain (Schoenwald et al. 2011), and
the CFI-FI accomplishes both tasks.
In line with Proctor et al.’s (2013) recommendations, CFI implementation strate-
gies for individuals and teams along seven dimensions whose clarity would con-
cretely operationalize implementation are discussed: 1) actors, 2) action, 3) action
target, 4) temporality, 5) dose, 6) implementation outcomes affected, and 7) justifica-
tion. Table 4–1 presents definitions for each of these seven dimensions. A side-by-side
comparison demonstrates how an implementation strategy can differ for individual
clinicians administering the CFI compared to a CFI implementation team with vari-
ous stakeholders. Each dimension of these implementation strategies is explained be-
low in greater detail.
Actor(s)
The actors involved in a CFI implementation strategy would differ for individual cli-
nicians and implementation teams. Individual clinicians may wish to implement the
CFI either without administrative support—as in private practice—or without orga-
nizational resources, such as time and funding, when they are not immediately ob-
tainable. The actors involved in implementation strategies for individual clinicians
would be the clinicians themselves. Implementation strategies for individual clini-
cians may provide direct performance feedback through the use of rating instruments
such as the CFI-FI. At the same time, implementation strategies for individual clini-
cians may not consider organizational resources that can aid implementation through
coordinated support from multiple actors.
Implementation strategies at the team level may involve actors from different back-
grounds who wish to introduce the CFI throughout an organization. Different func-
tions of a CFI implementation strategy may require individuals with different skill sets
and professional backgrounds. For example, individual clinicians will be ultimately
responsible for delivering the CFI to patients. At the same time, a CFI implementation
team may be composed of various individuals, such as administrators who can over-
see clinical use, outside consultants who may be involved in auditing, and payers who
maximize financial resources to encourage implementation. Training needs could also
TABLE 4–1. Specification of sample Cultural Formulation Interview (CFI) implementation strategies
Dimension Definition Strategy: individual clinicians using the CFI Strategy: CFI implementation team
Actor(s) Stakeholder(s) who deliver(s) Individual clinicians who are trained to deliver the CFI A team of clinicians and administrators
the implementation strategy to patients wishing to implement the CFI
throughout an organization
Action Steps, processes, and sequences Clinicians should be trained in the CFI and supervised CFI team should reflect on how the CFI is
of behavior outlined in the to ensure that the CFI is delivered with fidelity. being implemented within the organiza-
implementation strategy tion by sharing lessons learned, support-
ing learning and training programs, and
proposing changes as necessary.
Target of action Party thought to be affected by Individual clinicians using the CFI with patients; targets of All clinicians trained in the CFI and
the implementation strategy action can be measured through the clinician competence organizational stakeholders such as
and intervention distinctness subscales of the CFI-FI* administrators who ensure implemen-
tation
Temporality Order or sequence of the imple- Clinicians should 1) be trained in the CFI, 2) be super- CFI implementation team would deter-
mentation strategy vised for CFI fidelity with a test case soon after train- mine the exact order and schedule for
ing, and 3) use the CFI in practice. the implementation.
Dose Intensity of certain implementa- For training, dose is the amount of protected organiza- CFI implementation team would deter-
tion components, such as the tional time spent learning the CFI; for execution, dose is mine the time spent for each imple-
time spent in training and the measured by the number of core CFI questions asked as mentation step.
frequency of audit or feedback rated by the CFI-FI*; for evaluation, dose is the amount
of time that the organization provides feedback.
Implementation Effects of deliberate and purpo- CFI uptake, penetration among eligible patients, and CFI uptake, penetration among eligible
outcomes sive actions to implement inter- fidelity of CFI implementation* patients, fidelity to the CFI, long-term
ventions in health care settings sustainability, and costs*
Justification Justification or rationale for Asking patients about their cultural views on topics Cooperative learning theory may aid the
strategies used to implement covered by the CFI may improve satisfaction with the entire team with implementation at the
an intervention provider and participation in treatment. organizational level.
Note. CFI-FI=Cultural Formulation Interview–Fidelity Instrument.
195
*See subsection on this dimension in text.
vary depending on whether the organization hires employees to monitor needs inter-
nally or contracts training to outside parties. To optimize chances that clinicians will
implement the CFI, administrators should assign implementation functions matched
to knowledge, skills, and organizational responsibilities. The strengths of a team-
based approach can be peer support and formal institutional policies around imple-
mentation, although more costs and personnel may be needed to implement the CFI
at a team level than at the individual level. Individuals and organizations can deter-
mine which implementation strategies to use based on available resources to optimize
successful CFI fidelity.
Action
Ideally, actions are itemized in detail before an implementation strategy is operational
to increase the likelihood of successful implementation (Proctor et al. 2013). Training
clinicians in the use of the CFI is an essential component for implementation strate-
gies at both individual and team levels. Clinicians should be trained in the use of the
CFI through a formal session that consists of four components: 1) reviewing the CFI’s
written guidelines in DSM-5, 2) observing a simulation of the CFI in use, 3) simulating
the CFI through practice cases, and 4) asking questions for clarification. These four
training modalities help guarantee that psychosocial and behavioral interventions
are disseminated in a standard fashion with a training protocol that can be replicated
in diverse organizations (Rounsaville et al. 2001). These modalities help to ensure that
the CFI is delivered with fidelity through rigorous quality control.
Some have questioned whether all four modalities of training are actually neces-
sary given the resources needed (e.g., opportunity costs of productivity), especially
with the introduction of newer technologies that can scale up training (Beidas et al.
2011). Nonetheless, there is now consensus that passively watching presentations and
video demonstrations—known as the “train and hope” approach (Henggeler et al.
2002)—may change clinician knowledge but do not necessarily change clinician be-
havior without behavioral simulations and small group discussions that provide
feedback on active performance (Beidas et al. 2012; Dimeff et al. 2009; Miller et al.
2004). The gold standard array of passive and active learning modalities has been
used in training clinicians for the DSM-5 CFI field trial. It is an open question whether
a particular mix of training modalities improves clinician CFI fidelity, and organiza-
tions that implement the CFI may not have the resources to complete all four training
modalities. In all instances, we recommend that the actors responsible for executing
the CFI implementation strategy—whether individual clinicians or entire implemen-
tation teams—first identify training modalities that match their needs and resources.
After training has been completed, supervisors can assess clinicians on their fidel-
ity to the CFI. Systematic reviews have shown that fidelity has been measured
through the following five constructs (Dusenbury et al. 2003):
1. Clinician adherence to methods—the extent to which the implementation of inter-

vention activities and methods corresponds with written instructions
2. Clinician competence—the extent to which a provider delivers intervention con-
tent in a way that is considered ideal by intervention developers
3. Participant responsiveness—the extent to which participants are engaged by and

involved in the intervention
4. Intervention distinctness—core principles specified to ensure the uniqueness of an
intervention so that it can be reliably differentiated from other interventions
5. Dosage—the amount of intervention received by participants
Researchers at the New York State Psychiatric Institute have tested how each of
these five subscales could be used to measure CFI fidelity with New York City partic-
ipants in the DSM-5 field trial. We found that raters who evaluated fidelity by listen-
ing to interviews independently (not with each other) reached the same score
(interrater reliability) in over 60% of their ratings for the first four subscales: 1) clinician
adherence to CFI question topic, 2) clinician competence throughout the overall inter-
view, 3) participant (i.e., patient) responsiveness, and 4) intervention distinctness
(Aggarwal et al. 2014). The value of 60% has traditionally been a benchmark of high
interrater reliability that produces dependable ratings (Grove et al. 1981). (A full
rater’s manual is available via e-mail from the author.) Tables 4–2 and 4–3 present a
revision of the CFI-FI keyed to the core CFI included in DSM-5; the field trial version
differed slightly.
Modifications to interventions, training protocols, and fidelity measures should
change based on ongoing intervention development; just as interventions change, so
should fidelity measures because “one size cannot fit all” (Carroll and Nuro 2002).
Consequently, the CFI-FI below has been updated to include topics that were added
after completion of data collection in the DSM-5 field trial. Tables 4–2 and 4–3 make
up the two parts of the revised CFI-FI. Table 4–2 rates fidelity by core CFI question,
whereas Table 4–3 rates the quality of the clinician’s delivery by examining general
factors throughout the interview. My colleagues and I believe that both checklists
should be used together for a holistic understanding of fidelity throughout the CFI
session.
Different constructs of fidelity yield separate types of information, each of which
is valuable in its own right. For example, it may be intuitive that clinician adherence
to the CFI hews closely to the content and order of the CFI topics. In developing the
CFI-FI, however, we found that patient responsiveness can affect clinician adherence
because patients suffering from serious mental illness may not answer cultural ques-
tions relevantly because of cognitive burden (Aggarwal 2012); therefore, clinicians
may eventually stop asking CFI questions if patients do not answer or if they provide
answers that are not relevant (Aggarwal et al. 2014). In these situations, the CFI-FI al-
lows clinicians and administrators to identify points throughout the CFI when adher-
ence to individual questions waned based on patient responsiveness.
Similarly, the core CFI (see Appendix A of this handbook) has been designed with
questions in a specific order and is intended to produce cultural information that in-
fluences the direction of the subsequent standard clinical assessment. The serial order
of questions and the information covered in each cultural topic distinguish the core
CFI from other types of intake interviews. The CFI-FI assumes that the CFI will be de-
livered in order and in its entirety. Future work can determine whether this approach
is the best way to rate fidelity or whether there are better ways. For example, clini-
cians may find that interspersing sections of the standard clinical assessment with the
198
TABLE 4–2. Cultural Formulation Interview–Fidelity Instrument subscales of clinician adherence and patient
responsiveness
Clinician adherence: Patient responsiveness:

Did the clinician ask a core Did the patient answer
CFI-FI question based on core CFI topic CFI question about...a about... b
1. The patient’s presented problem?

2. The patient’s description of the problem to members of the patient’s social network?

3. The severity of the problem? (The patient may not be experiencing any severity
at all, and this should still be coded.)
4. The causes of the problem from the patient’s perspective?
5. The causes of the problems from the perspective of the patient’s social network?
6. What makes the problem better?
7. What makes the problem worse?
8. The most important aspects of the patient’s background or identity?
9. How identity relates to the patient’s presented problem?
10. How identity relates to other concerns or difficulties?
11. Self-coping?
12. Past help seeking?
13. Barriers to care?
14. The patient’s current treatment preferences?
15. Current treatment preferences from the perspective of the patient’s social network?
16. Concerns about the clinician-patient relationship?
Total
a
Ratings: 0=no; 1=yes.
bRatings: 0=no; 1=response not relevant to core CFI topic; 2=response relevant to core CFI topic.
TABLE 4–3. Cultural Formulation Interview–Fidelity Instrument subscales of

clinician competence and intervention distinctiveness
Clinician
CFI-FI fidelity construct scorea
Clinician competence
Empathy: Did the clinician paraphrase or name the patient’s emotional state?
Patient centeredness: Did the clinician maintain a nonjudgmental attitude (not
arguing, confronting, or correcting the patient)?
Clarification: Did the clinician ask follow-up questions to understand unclear
patient responses?
Illness narration: Did the clinician’s interactions help the patient construct and
explore a narrative account of illness, or did the clinician seem to rush through
the core CFI?
Total
Intervention distinctness
Drift: Did the clinician stick to the CFI questions and not ask about topics that typ-
ically belong to the standard clinical interview (history of present illness, cur-
rent medications, detailed psychiatric or medical history, family history, social
history, Mini-Mental Status Examination)?
Order: Did the clinician ask about all topics in order as reflected in the core CFI
clinician guidelines?
Total
a
Ratings: 0=no; 1=throughout less than half of the interview; 2=throughout more than half of the inter-
view.
core CFI improves its implementation compared with asking all questions in strict,
successive order.
Finally, the elements that measure clinician competence can be seen as the extent
to which clinicians elicit complete and accurate responses to the CFI questions. Clini-
cian competence is not rated by question because some patients answer questions to
such a degree of completion that clinicians do not need to ask follow-up questions
(Aggarwal et al. 2014). For example, patients may describe the problem from their
point of view as well as from the perspectives of close associates such as family or
friends, obviating the need for the clinician to ask this follow-up question. In addi-
tion, my colleagues and I realized that dose—measured as time length of the core
CFI—was not a good measure of fidelity because some clinicians would not redirect
patients who answered tangentially, thereby increasing the time needed to complete
the core CFI and overall interview, whereas other clinicians could complete the core
CFI and standard assessment within a typical 1-hour session (Aggarwal et al. 2014).
Because the constructs differ conceptually and by scoring method, spaces are pro-
vided on the CFI-FI for separate total scores rather than an overall score. Ratings are
not tallied for the entire CFI-FI but for the individual constructs of clinician adher-
ence, clinician competence, patient responsiveness, and intervention distinctness. We

encourage raters to familiarize themselves with the CFI-FI before rating fidelity for
more accurate ratings.
The CFI-FI assesses fidelity at the patient-clinician level. This fidelity measure-
ment may suffice for implementation strategies tailored to individual clinicians.
However, implementation strategies at the team level may require additional mea-
sures of fidelity. Proctor et al. (2013) specifically refer to audit and feedback measures
to assess what has been completed and what remains to be done throughout all steps
of the implementation process. Audit and feedback measures have been defined as
summaries of clinical performance over a specified period of time, and they are par-
ticularly effective in situations where there is low baseline adherence to practice and
when feedback can be delivered intensively (Jamtvedt et al. 2006). Audit and feed-
back measures influence clinical practice when information is presented close to the
time of clinical decision making and when participants have agreed to receive such
feedback rather than viewing it as an imposition (Mugford et al. 1991). My colleagues
and I recommend that CFI implementation teams actively incorporate audit and feed-
back measures within implementation strategies to foster skill development and sat-
isfaction among all organizational stakeholders.
Target of Action
Implementation strategies should specify the targets of an intervention to help focus
the strategy and suggest how outcomes can be measured (Proctor et al. 2013). For this
reason, the CFI implementation strategies presented in this section vary by emphases
in their stated targets of action. An implementation strategy targeting individual cli-
nicians using the CFI with individual patients could focus on training and fidelity.
Training with the CFI is intended to increase practitioner knowledge and skill,
whereas fidelity checklists evaluate competence in administering the CFI after train-
ing. The CFI-FI measures of clinician competence in Table 4–3 may fulfill this need.
In contrast, an implementation strategy at the team level may include several
stakeholders. For instance, the organization may want information from patients and
administrators as well as from clinicians. Information from patients may come in the
form of satisfaction surveys and scales about clinicians’ CFI use in practice. This type
of information would communicate how the CFI was received among intended ben-
eficiaries; this target of action differs from clinician training and fidelity. As another
example, an implementation team may want to ask administrators about CFI use in
an organizational context related to time needed for completion, potential scheduling
concerns, billing procedures, and other practices that do not directly relate to the CFI
as an intervention but are, nonetheless, instrumental to its implementation. Review
of implementation and dissemination models has shown that implementation strate-
gies typically target more than one stakeholder to provide comprehensive informa-
tion (Tabak et al. 2012), and organizations implementing the CFI may find that
information from multiple stakeholders clarifies decision making. For example, if cli-
nicians deliver the CFI with fidelity but administrator feedback indicates difficulties
with scheduling due to increased time spent per patient, then implementation teams
can deliberate over how to use the CFI more efficiently.
Temporality
Temporality refers to the sequence of steps in an implementation strategy. An imple-
mentation strategy focused on clinicians might begin with CFI training, followed by
supervision with one case through ratings of fidelity and then implementation with
patients. This sequence of steps corresponds to general frameworks for introducing
interventions to clinicians when fidelity is vital to prevent intervention drift (Carroll
and Nuro 2002; Gearing et al. 2011; Rounsaville et al. 2001). Active feedback to clini-
cians through CFI-FI ratings may improve practice if provided soon after the first
case. This temporality also may make intuitive sense: attempts to measure CFI fidel-
ity may be met with resistance without a prior training session.
Similarly, a CFI implementation team may benefit from planning the sequence of
steps necessary for an implementation strategy. Models of implementation can differ
with respect to the number of exact steps needed to introduce and sustain an inter-
vention in health care settings, but they all involve planning, executing, and evaluat-
ing (Proctor et al. 2013). A CFI implementation team can map out the sequence of
steps with start and end dates to assess whether any step takes longer than antici-
pated and how members of the team can respond to implementation barriers.
Dose
A persistent question in research on intervention development and implementation
science concerns the amount of the intervention delivered by clinicians and received
by beneficiaries (Gearing et al. 2011; Rounsaville et al. 2001). Unlike medications, psy-
chosocial interventions—including interviews such as the CFI and specialized forms
of psychotherapy such as cognitive-behavioral therapy—do not come from a single
manufacturer who can guarantee quality, so dose (or intensity) depends on the skills
of the implementer (Carroll and Nuro 2002; Rounsaville et al. 2001). Researchers and
practitioners involved with any intervention should measure dose so that others can
learn about the minimal dose needed to achieve the strongest effect (Proctor et al.
2013).
A CFI implementation strategy can measure dose in two ways, depending on the
level of implementation. For individual clinicians, dose can be measured by complet-
ing the CFI-FI checklist in Table 4–2, rating the clinician’s adherence to asking each of
the 16 questions in the core CFI. At the organization level, dose can be measured
through the sequence of steps outlined in the “Temporality” section. Key variables in-
clude the time and intensity spent on training, the time and intensity of the phase
when the CFI is implemented, and the time and frequency of audit and feedback mea-
sures (Proctor et al. 2013).
Implementation Outcomes
The multidisciplinary nature of implementation and dissemination science has led
practitioners and researchers to propose multiple outcomes, often without clear def-
initions and means of measurement (Grimshaw et al. 2006). For this reason, imple-
mentation scientists have suggested a common taxonomy to measure implementation
outcomes—defined as the effects of deliberate, purposive actions to implement new
interventions—so that implementers can evaluate implementation success and inter-

mediary processes (Proctor et al. 2011). This framework has informed analyses of CFI
feasibility and acceptability among patients and clinicians in the DSM-5 field trial
(Aggarwal et al. 2013a; Lewis-Fernández et al. 2014); Table 4–4 presents these out-
comes based on the work of Proctor et al. (2011). The “Level of Analysis” column in-
dicates at what levels this information can promote implementation strategies:
consumer, clinician, and organization.
Implementation strategies need not target every single implementation outcome,
but they should be explicit in which outcomes are selected, how they are measured,
and at what phase of implementation they are measured (Proctor et al. 2013). This
perspective can inform how CFI implementation teams select suitable outcomes for
measurement. For example, in the planning phase of CFI implementation, interviews
with clinicians and administrators may clarify outcomes of acceptability (whether peo-
ple like the CFI) and appropriateness (whether the CFI is seen as relevant). In the exe-
cution phase, fidelity can be measured after training via CFI-FI ratings, adoption can
indicate how many providers are using the CFI, and feasibility can suggest whether
and which providers think that the CFI is practical or not within service constraints.
In the evaluation phase, penetration may be measured by examining the numbers of
providers who use the CFI or the numbers of patients with whom the CFI has been
used after an initial trial period, whereas sustainability would focus on the integration
and routinization of the CFI within everyday practice. At all implementation phases,
administrators may want to assess cost.
Stakeholders may also differ in their perceptions of which implementation out-
comes are pertinent (Proctor et al. 2011). For example, cost may be most important to
service administrators, feasibility to providers, acceptability to patients, and fidelity to
trainers and CFI developers. For this reason, the two sample CFI implementation
strategies compared in Table 4–1 emphasize slightly different outcomes. Both imple-
mentation strategies would ideally address CFI uptake, penetration among eligible pa-
tients, and fidelity of CFI implementation. In addition, implementation strategies for CFI
teams may also focus on long-term sustainability and costs, especially to address hu-
man resources issues that may not concern individual clinicians, such as ongoing staff
training, staff attrition, and rehiring. Clarity about which implementation outcomes
are being measured, at what implementation phase, and through which specific mea-
surements may help CFI clinicians, administrators, and researchers to evolve a com-
mon language and comparative framework.
Justification
Proctor et al. (2013) recommend that clinicians, administrators, and researchers justify
any intervention and associated implementation strategies so that potential needs,
barriers, and facilitators related to implementation can be addressed to promote prac-
tice change. This rationale can be applied to the two implementation strategies
focused on clinicians and organizations in Table 4–1. For example, research demon-
strates that interventions by clinicians on patient cultural views increase patient par-
ticipation throughout the interview, clinician-patient information exchange,
TABLE 4–4. Implementation outcomes for a Cultural Formulation Interview (CFI) implementation strategy
Implementation
outcome Definition Level of analysis Implementation stage Methods for measurement
Acceptability Perception among implemen- Individual provider or indi- All stages Surveys, interviews, or
tation stakeholders that the vidual consumer administrative data
CFI is agreeable
Adoption Intention or initial decision to Individual provider or organi- Early to middle Surveys, interviews, or
use the CFI in practice zation administrative data
Appropriateness Perceived fit or relevance of Individual provider, individ- Early (before actual adoption) Surveys, interviews, or focus
the CFI for a given setting, ual consumer, or organiza- groups
provider, or consumer tion
Cost Resources necessary to imple- Organization All stages Administrative data
ment the CFI
Feasibility Extent to which the CFI can be Individual provider or organi- Early (during adoption) Surveys, interviews, or
successfully used within zation administrative data
practice constraints
Fidelity Degree to which the CFI was Individual provider Early to middle Checklists (CFI-FI), observa-
implemented as intended tion, self-report
Penetration Integration of the CFI within Organization Middle to late Case audit, checklists
the service setting
Sustainability Extent to which the CFI is Organization Late Case audit, interviews, check-
maintained or institutional- lists
ized in an ongoing, stable
manner
Note. CFI-FI= Cultural Formulation Interview–Fidelity Instrument.
Source. Adapted from Proctor et al. 2011.
203
interpersonal rapport, and overall patient satisfaction (Newes-Adeyi et al. 2004; Paw-
likowska et al. 2012; Roter et al. 2012; Tibaldi et al. 2011). In interviews with patients
and clinicians participating in the DSM-5 field trials, the CFI was shown to improve pa-
tient satisfaction throughout the interview, obtain information necessary for diagnosis
and treatment, elicit the patient’s perspective, and help clinicians piece together infor-
mation (Aggarwal et al. 2013a). My colleagues and I believe that these findings justify
implementation of the CFI among clinicians. Similarly, organizational implementation
strategies should be based on relevant theory, empirical evidence, and/or practical
data (such as low costs or ease of implementation) (Proctor et al. 2013). Proctor et al.
(2013) recommend cooperative learning theory as a justification for implementation
strategies. Cooperative learning differs from competitive or individual learning in that
stakeholders work together to accomplish common goals that are 1) explained through
clear objectives, 2) discussed in small groups, and 3) emphasized through individual
accountability (Johnson et al. 1998). We agree that this approach may help stakeholders
advance CFI implementation. For example, groups of clinicians and administrators
can separately discuss factors that enhance or detract from CFI implementation, shar-
ing tips on what has worked and not worked to encourage positive information ex-
change and group interdependence. Groups meeting on a set schedule can serve as a
mechanism for internal checks and balances in the form of an audit-and-feedback mea-
sure. CFI implementation strategies that are not based on a justification that convinces
relevant stakeholders are likely to encounter resistance.
Conclusion
In this chapter, two sample CFI implementation strategies based on Proctor et al.’s
(2013) guidelines to specify and report elements that are crucial to the implementa-
tion of any intervention have been recommended. My colleagues and I have selected
this framework because it represents the first attempt to identify and standardize
common elements of successful implementation strategies. Our purpose has not been
to favor this framework over others but to evolve a common framework for clinicians,
administrators, and researchers interested in the CFI. The use of CFI implementation
strategies can help promote understanding of what steps and processes may be useful
in implementing the CFI within particular contexts through detailed descriptions.
Such understanding about which CFI implementation strategies work and why can
inform clinical practice and future research questions on what needs adaptation to
safeguard implementation success.
KEY CLINICAL POINTS

• Implementation science can help clinicians and administrators implement the Cul-
tural Formulation Interview (CFI) within clinical practice.
• Implementation strategies can be customized for those responsible for implement-
ing the CFI into their unique practice setting.
• Implementation strategies can predetermine what outcomes are most important to

measure.
• The Cultural Formulation Interview–Fidelity Instrument can be used to measure
how well and how completely the CFI was administered.
Questions
1. What is implementation science and how can it help with implementing the
CFI in practice settings?
2. What are implementation strategies and how can they be used to implement
the CFI?
3. What are the seven dimensions common to all implementation strategies?
4. How do implementation strategies for the CFI differ for individual clinicians
and implementation teams?
4. What are the subscales of the Cultural Formulation Interview–Fidelity Instru-
ment?
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Suggested Readings
McGill University: CCS Cultural Formulation. Montreal, Canada, McGill University, 2014.
Available at: http://www.mcgill.ca/iccc/resources/cf. Accessed September 15, 2014. Mc-
Gill University hosts this Web site on how the CFI’s precursor, the OCF, has been imple-
mented in different service settings around the world.
National Information Center on Health Services Research and Health Care Technology (Na-
tional Institutes of Health): Health Services Research Information Central. Bethesda, MD,
National Institutes of Health, 2014. Available at: http://www.nlm.nih.gov/hsrinfo/
implementation_science.html. Accessed September 15, 2014. The National Institutes of
Health hosts this Web site, which acts as a clearinghouse for different tools, instruments,
meetings, and conferences on implementation.
New York State Office of Mental Health, Center of Excellence for Cultural Competence: Cultur-
al Formulation Interview Project, 2013. Available at: http://nyculturalcompetence.org/
research-initiatives/initiative-diagnosis-engagement/cultural-formulation-interview-
project/. Accessed September 15, 2014. This site hosts publications, videos, and training
modules on the CFI.
Use of the Cultural Formulation
Interview in Different Clinical Settings
Two basic and complementary premises set the stage for the content of this
subchapter: 1) culture has a pervasive presence in every level, aspect, and setting of a
clinical activity, and 2) the clinician needs to ascertain the impact of culture on the pa-
tient’s suffering and the evaluation process (Alarcón 2009; Kirmayer et al. 2003). The
Cultural Formulation Interview (CFI) is a semistructured instrument that can help cli-
nicians elicit and document the cultural aspects of any patient’s diagnosis and treat-
ment plan arrived at through a comprehensive evaluation. As discussed throughout
this volume, the purpose of the CFI is to expand on the clinical information obtained
through standard diagnostic assessments of the patient’s explanatory, coping, and
help-seeking efforts and to elicit more information about the social context that can
reveal both pathogenic and potentially therapeutic factors (Alarcón et al. 2009) (see
subchapters “Supplementary Module 1: Explanatory Model” and “Supplementary
Module 7: Coping and Help Seeking”).
The diagnostic process does not take place in a vacuum. The clinical setting in
which the evaluation occurs can play a decisive role in the way patients and their rel-
atives tell their story. Aspects of the setting that influence the clinical encounter in-
clude its physical environmental characteristics; the type and roles of professional
and ancillary staff present; the dynamic interactions between professionals, patients,
and their entourage; and institutional norms and procedures. Furthermore, the path-
ways to care affect the setting. Many patients come to hospitals or clinics after a com-
plex process of self-negotiations and interactions with people they trust, whereas
others are brought against their will because of the overwhelming nature of their clin-
ical symptoms and as a result of decisions made by persons they have never met.
The differences in pathways to care and among the settings where the clinical
encounter takes place may require variations in the use of the CFI. To illustrate this
variation, we focus in this subchapter on emergency departments (EDs), consulta-
tion-liaison services (i.e., inpatient medical and surgical units in general hospitals),
outpatient clinics, as well as urban and rural community health centers. We describe
each setting in terms of its environmental and patient- and staff-related features; clin-
208
Use of the CFI in Different Clinical Settings 209
ical vignettes illustrate key issues. We also discuss technical aspects of the application
of the CFI and its potential use in the context of collaborative or integrated care ap-
proaches to the provision of health and mental health services.
Emergency Departments
Clinical work in EDs is characterized by time urgency, especially the pressure to con-
duct a relatively thorough evaluation of the patient in a short period of time (Jarvis
2014). Cases seen in ED settings usually reflect disparities between patients’ clinical
needs related to complex symptomatology and the coping resources available in their
immediate surroundings (including family and social support and financial options)
(Allen et al. 2002; Hart and Alarcón 2006). These characteristics can make the ED en-
vironment, on occasion, seem chaotic. ED work has been described as the highest ex-
pression of multidisciplinary activity in the field of medicine, because of the presence
of patients from all walks of life who have multiple, complex, and sometimes dra-
matic pathologies (Lettich 2004). In recent decades, because of increased demands for
medical services in general and mental health problems in particular, EDs have be-
come the entry point for patients with all kinds of conditions regardless of severity,
thus making the atmosphere even more fluid and unpredictable. The circumstances
of each patient’s arrival and the presence of family members bring important cultural
dimensions to assessment and care in this setting (Chanmugam et al. 2013).
The most frequently seen psychiatric presentations in EDs are psychotic crises or
psychomotor agitation episodes of different origins, suicidal behaviors, and compli-
cations from drug or alcohol intoxication. From the sociodemographic perspective, an
ED becomes a sort of “final common pathway,” a setting in which patients of all social
classes, educational levels, and ethnic origins converge for care of similar clinical con-
ditions. This feature makes the setting eminently multicultural. Migration phenom-
ena of all kinds contribute to this diversity, particularly in urban general hospitals.
Video 18 depicts a portion of the core CFI interview in the ED setting.
Video Illustration 18: I’ve been feeling really frustrated (4:20)
This video illustrates the use of the core CFI in the ED through an interview
with a young man of Guatemalan descent who is being evaluated for suicidal
ideation after the death of his baby daughter. The interview shows how the
core CFI functions well in a situation of acute symptomatology. Despite his in-
tense frustration and anger, the patient answers every question. He elaborates
on being “out of control” and how he feels that nobody understands. He de-
scribes his ambivalence toward his main source of support, his wife, “The only
person who understands me right now is my wife, and I don’t know why she
brought me here, I don’t know why she pushed me to get here.” He is able to
communicate his sense of urgency, but he also evidences a perhaps unacknowl-
edged willingness to seek help by talking about his family disagreements and
the distressing nature of his suicidal ideation, shame, and emotional confusion.
The core CFI questions also elicit more information that could help the ED cli-
nicians calibrate the level of severity of the situation and arrive at a treatment
recommendation. The ED is probably the setting where patients’ causal attri-
butions emerge more loaded with feeling and also more spontaneously. In this
case, the patient feels “God is trying to test me...to see if I am strong enough
to deal with what happened right now, with losing my baby. To be honest, I
don’t feel strong.... I feel at times really upset, and I feel like I don’t have the
control to move on, and to push forward.” The dissonance between his sense
of a loving God and of himself as a strong man and his current feeling of aban-
donment, of existential emptiness, likely contributes to his suicidal ideation.
His family is supportive, particularly his wife, but most of his relatives are far
away in Guatemala, and in any case, he is not sure they “would understand.”
The core CFI offers an opportunity for the patient to describe his situation in
his own terms, and what emerges in this case is a rich account of the patient’s
suffering, his distressing interpretations of his condition, and his lack of sup-
port. It also gives the patient a chance to express himself more fully, unburden-
ing himself of his internal turmoil. The patient himself seems to acknowledge
his need for help; despite his angry responses, he never asks to be discharged
from the ED.
Tools such as the core CFI are extremely relevant to ED work because of the cul-
tural impact on the psychiatrist’s primary tasks of diagnosis and disposition, which
involve assessing complex situations that may generate psychological and somatic
symptoms as well as variable behavioral responses (Chincilla Moreno 2012; Triplett
and DePaulo 2013). The core CFI is a flexible instrument, adaptable to the vicissitudes
of the ED setting. The following two clinical examples illustrate its potential utility.
Case Vignette 1
Carlos, age 18, was brought by a paternal aunt to the ED of the local hospital in a mid-
size Andean city in Peru. He felt “ashamed and humiliated” after his father strongly ad-
monished him in front of his friends. He then experienced acute nausea and headaches
and felt “physically ill.” Examinations by an internist and several specialists and a va-
riety of laboratory tests were negative. He received symptomatic medications but expe-
rienced no relief. The patient demanded intravenous fluids; when the doctors refused,
he lost consciousness for a short period. The ED psychiatrist was then called in.
The patient appeared shy, fearful, and anxious but provided coherent information.
He reported similar problems in the past, did not verbalize suicidal or homicidal ideas,
and did not have psychotic symptoms. When asked about the cause of his problems,
Carlos recognized the triggering impact of the “shame” he experienced after his fa-
ther’s reproaches and reaffirmed his belief that intravenous fluids would alleviate this.
The psychiatrist then talked with the patient’s aunt, a registered nurse who suggested
that the “diagnosis” of her nephew was possibly chucaque, a cultural concept of distress
described in some Andean countries. Encouraged by the psychiatrist’s attention, she
explained that this term was accepted in her cultural milieu of origin but that she was
afraid to endorse this explanation, much less to suggest it, because as a nurse she knew
that “doctors don’t believe in chucaque.” The psychiatrist’s empathetic interaction with
the patient afterward actually “validated” the patient's understanding of the problem
and supported a culturally acceptable management that resulted in a significant im-
provement of Carlos’s clinical condition.
Case Vignette 2
Carmen, a 45-year-old widow who has lived her entire life in a remote region of a Latin
American country plagued by massive political violence, arrived at the ED of a city hos-
pital after a long and arduous journey. She came in accompanied by several members
of her family, who provided a recent history of social isolation, refusal to leave the
house, neglect of her usual activities, anxiety, and distrustfulness. She only spoke her
native language, Quechua, and as the ED clinician spoke only Spanish, the interview
had to take place with the assistance of a nurse interpreter, a circumstance that made
the patient even more reticent. To the question of whether Carmen had been seen “talk-
ing to herself,” the relatives responded affirmatively, but the impression of the inter-
viewing clinician was that because of their timidity, they seemed ready to answer “yes”
to every question and were unwilling to contradict the doctors. Another relative, a
young man who had migrated earlier to the urban coastal region of the country, re-
ported that Carmen had been a teacher in the local school, but in recent years had been
doing her work at home; she was afraid to leave it because she had been repeatedly
threatened during the period of terrorist violence. Further questioning allowed the clin-
ical team to rule out schizophrenia and focus on a possible posttraumatic stress disor-
der. They were also able to identify some cultural factors that had contributed to the
delay in seeking professional help. These included mutual distrust and suspiciousness
of neighbors who identified themselves as supporters of the people who had threat-
ened Carmen and her own conception of her problem as susto (fright illness), an emo-
tional condition subsequent to the experience of intense emotions.
The use of several sections of the core CFI would likely have helped in the task of eval-
uating the cultural aspects of the clinical and diagnostic realities of these two patients. In
Carlos’s case, for instance, eliciting the patient’s cultural definition of the problem and the
cultural perception of the cause and employing the use of specific local, colloquial terms
(i.e., chucaque) might have facilitated a faster rapport. The patient had not sought help in
the past, and exploring the absence of previous help seeking could have broadened the
understanding of a complicated cultural background, which also strongly influenced his
father’s attitude and behaviors. The aunt’s cautious approach changed after the psychia-
trist entered into the family’s cultural world by asking clinical questions in concrete cul-
tural terms, as the CFI suggests. In Carmen’s case, social and political realities had pushed
the patient into a state of isolation, doubt, rumination, and overwhelming fear. The fam-
ily’s support was heartfelt but, because of the same fears and doubts, expressed itself
through a help-seeking process of limited scope and resulted in longer delays in treat-
ment for Carmen than for patients who follow more conventional pathways.
These two patients and their relatives conducted their relationships with the pro-
viders in an ambiguous manner, particularly initially. In this connection, the core CFI
could also have helped to clarify crucial issues of cultural identity that influenced the
clinician-patient interactions. Carlos was an adolescent subordinated to an authoritar-
ian parental style but was able to respond to an empathetic approach that used his own
cultural-syndromic language. Carmen was a member of a population attached to their
original language, customs, traditions, habits, and beliefs and was distant and distrust-
ful of city-based providers, all the more so because of her traumatic experiences. For-
tuna et al. (2009) explain the advantages of a culturally informed model that can help
assess factors “that affect the experience and interpretation of illness as understood by
the patient, the family and the social network” (p. 434). In Peru, epidemiological inves-
tigations conducted by the country’s National Institute of Mental Health have found a
high prevalence of cultural concepts of distress such as susto and chucaque (Bernal-
García 2010a, 2010b), supporting the inclusion of these well-established entities in the
process of differential diagnosis in order to enhance diagnostic accuracy. The core CFI
can play a decisive role in such epidemiological investigations.
The participation of interpreters is an important aspect of intercultural clinical work
in emergency psychiatric settings. The cultural information provided by the interpreter
in Carmen’s case may have unintentionally obscured the meaning of some behaviors,
including the coping activities aimed at helping her overcome her susto-like experience,
which were not highlighted in the original translation. In ED settings in particular, in-
terpreters’ accuracy in conveying certain cultural phenomena, such as the nuances of
an experience that might be construed as a delusion (particularly of the religious type),
is crucial, because the clinician’s conclusion in this regard may frame how he or she cal-
ibrates the severity of certain behavioral manifestations, understands the patient’s cop-
ing mechanisms, and directs (or redirects) management interventions.
In addition to a well-conducted interview based on the core CFI in the ED setting,
the supplementary modules can serve as useful clinical tools. For example, Carmen
could have benefited from an adapted version of the Immigrants and Refugees sup-
plementary module. The choice to deepen the inquiry in some sections of the core CFI
will depend on the clinician’s appropriate use of all the CFI components and correct
understanding of the patient’s cultural context.
Consultation-Liaison Psychiatry
By providing specialized services in the context of medical and surgical units in gen-
eral hospitals, consultation-liaison (CL) psychiatry represents a historically progres-
sive move toward comprehensive care (Kimball 1979). Cultural psychiatric
consultation in medical settings, the newest addition to the CL approach, constitutes
both a challenge and an opportunity to explore many aspects of the illness experience
(Dominicé Dao and Kirmayer 2014).
The overall environment of general hospital CL settings is profoundly different
from that of psychiatric units, not only for the nature of the clinical problems under
treatment but also because of the presence of team staff members whose immediate
attention is focused on medical conditions. The psychiatric consultant is called to see
patients with overt physical problems, some of which are severe and exhausting; re-
ferral to a mental health specialist can be experienced as an additional stressor that
makes these patients feel misunderstood, even humiliated. “I didn’t come to see a
shrink!” is a very common greeting from patients, who thereby raise a crucial barrier
to their engagement with the psychiatrist; the situation may be further complicated
by the presence of relatives who are equally or more insistent on a strictly medical ap-
proach. This concern, related to the dualism of biomedicine (Miresco and Kirmayer
2006), has a lot to do with cultural preconceptions about causality, course, and out-
come of the disease. It also raises feelings of demoralization defined by subjective in-
competence, denial, breakdown of the patient’s “assumptive world,” and subsequent
distress (De Figueiredo and Gostoli 2013; Frank and Frank 1991). Although the pres-
ence of family poses challenges, the problem may be more complicated if, contrarily,
no relatives are involved and the patient’s feelings of abandonment, neglect, loneli-
ness, and bitterness challenge the rapport-building efforts of the CL psychiatrist.
Furthermore, the psychiatrist often has limited time for the consultation and must
focus on the clinical symptomatology to assess the case and recommend interven-
tions for the problems identified by the referring physician. Given the complexity of
CL cases, the psychiatrist should not come with preconceived diagnostic notions of
“reactive depression,” “illness anxiety disorder,” or “psychiatric disorder due to a
medical condition.” Psychiatric problems commonly seen in CL settings include
mood, cognitive, and adjustment disorders, but in many cases, they involve what
have been called “ambiguous requests for consultation” (Arbabi et al. 2012). In not a
few cases, the reasons for a referral stem from problems in the relationship between
the patient and the clinical team or the institution. The use of the CFI can help to un-
cover such systemic issues, including discrepancies between the patient’s under-
standing of the problem and the assumptions of the treatment team.
In addition to clarifying the specific issues described in the consultation request,
the task of the CL psychiatrist requires examining cultural factors, both immediate
and distant, that are affecting the clinical encounter. The importance of these factors
is suggested by Collins et al.’s (1992) findings about differences in rates of and reasons
for referral, overall prevalence of psychiatric disorders, and specific diagnoses among
patients from different U.S. ethnic groups. These differences include lower rates of re-
ferral for Latinos than for whites, African Americans, and Asians; more frequent di-
agnoses of depression and suicide for Latinos; more notations of “grossly abnormal
mental status” for blacks; and more diagnoses of adjustment disorder for Latinos,
“primary thought disorder” and delirium among African Americans, and dementia
for white patients (Collins et al. 1992). It must be kept in mind, however, that these
variations may not reflect genuine cultural differences among the patient groups but
rather biases in assessment and diagnostic practices.
Finally, broader health-related factors, such as the patient’s age, may be decisive
considerations in CL settings. Approaches such as Liaison Old Age Psychiatry
(LOAP) have been shown to effectively reduce the overutilization of health resources
through early identification of delirium, depression, and dementia (Nogueira et al.
2013). A similar reduction in overutilization may be observed as a result of CL ser-
vices provided to children and adolescents. Kitts et al. (2013) report high satisfaction
with the service of consultants, the effectiveness of their communication, the perti-
nence of their recommendations, and, above all, the helpfulness of interventions pro-
vided to both parents and youth. The issues of comprehensiveness of care and
prevention are crucial for this type of service.
Although any of the core CFI sections and any of the supplementary modules may
be particularly relevant in specific cases, the following components of the core CFI ap-
pear to be especially important in CL settings:
Cultural Perceptions of Cause, Context, and Support: The psychiatric component of

the patient’s illness may be seen by the patient and members of his or her social
network mostly as a reaction to the stressor of the illness—that is, an unwanted
complication—rather than a health problem in its own right. The evaluator should
discreetly attempt to go beyond these arguments to identify deeper concerns, in-
cluding fears, uncertainties, and related demoralization. This process highlights
the value of exploring illness explanations, meanings of physical/somatic symp-
toms, and their interaction with emotional states.
Cultural Factors Affecting Self-Coping and Past Help Seeking: Understanding patients’
coping or stress management styles is important for identifying individual vul-
nerabilities and sources of resilience that can be mobilized. Similarities with and
differences from previous illness experiences should be explored in an effort to re-
inforce successful strategies that can be used again. Previous experiences in health
care settings provide clues to a patient’s perceptions of and response to the current
hospitalization, as well as his or her understanding of the circumstances and
meaning of the consultant’s visit to the medical or surgical inpatient unit.
Cultural Factors Affecting Current Help Seeking: Relationships with the consultant as
well as members of the referring clinical team are relevant. At times, the referral re-
veals a certain degree of “imposition” by the professional staff who requested the con-
sultation. Acknowledging this and identifying the nature of the patient’s relationship
with the staff members of the referring unit may provide reassurance about the objec-
tives and focus of the consultation and contribute to improving clinical care.
CL psychiatry services are expanding globally. Reports from different continents

and countries (Aghanwa 2002; Botega 1992; Maharajh et al. 2008; Ularntinon 2012;
Wand et al. 2009) indicate that this modality has become an essential component of
everyday hospital work. Comparative studies of CL practice across different regions
(Huyse et al. 2000; Kishi et al. 2007) confirm this trend. The cultural ingredients of CL
psychiatry entail many dimensions of identity and context beyond categories of race
and ethnicity. In particular, awareness of religious factors can enhance CL interven-
tions (Waldfogel and Wolpe 1993). The disparities in quality of care observed in sev-
eral studies (Delphin-Rittmon et al. 2012) reaffirm the need for comprehensive
assessments with tools such as the CFI.
Outpatient Settings
Most of the issues examined in this section are based on work with the core CFI at the
National Hospital Cayetano Heredia (HNCH) in Lima, Peru, one of the sites of the
DSM-5 international field trials (American Psychiatric Association 2013; Lewis-
Fernández et al. 2014). The main clinical conditions affecting those regularly attending
the HNCH psychiatric outpatient department were depressive and anxiety disorders,
schizophrenia, family or marital dysfunction, and the consequences of sexual abuse
(Barrón-Del Solar et al. 2012). The CFI field trial included 36 patients with major de-
pression, anxiety disorders (mainly panic disorder), substance use disorders (particu-
larly alcohol and cocaine), or eating disorders; two patients with somatoform
disorders; and one patient with gender identity disorder.
A psychiatric ambulatory care facility inserted in a general urban hospital must
address the diversity of its patients in terms of help-seeking patterns, referral modal-
ities, clinical presentations, and cultural features, including geographical origin, lan-
guage, religion, migration status, and socioeconomic condition (Kinzie and Leung
2004). This was the case with the field trial sample, except for socioeconomic status,
which was more uniform. Most patients had 8–10 years of education, came from
lower-middle-class or working-class backgrounds, and were generally underem-
ployed. Although most of the patients were self-referred or referred by other mental
health professionals, a substantial minority came to the outpatient department fol-
lowing the advice of nonpsychiatric health professionals who perceived the primarily
emotional or psychiatric nature of their complaints. The outpatient department tends
to be a somewhat less hectic place than the ED; the staff typically has more time to
evaluate the patients, although a variety of logistical demands make the availability
of time an unpredictable feature of the setting.
The information gathered through the use of the core CFI in an outpatient depart-
ment covers most or all areas of the interview. Patients in this setting tend to assert
particular beliefs about what are the causes of their health problems, who must con-
duct the treatment, and how it must be done; all of these views affect patients’ even-
tual adherence to the therapeutic regimen. A study conducted in Lima before the
DSM-5 field trial, using clinical vignettes of typical cases of major depression, panic
disorder, and schizophrenia, identified some beliefs that could interfere with the ap-
propriate management of these conditions in an outpatient setting (Castro-Cuba Tor-
res et al. 2013). For instance, study participants presented with vignettes of individuals
with panic disorder often assumed that the case descriptions were of people with a
physical illness that had not yet been diagnosed, so they expected little or nothing of
value from a psychiatrist’s intervention. Similarly, the belief that depression is caused
by “weakness of character” combined with “everyday life problems” led study par-
ticipants to make management suggestions such as leaving home; having fun; taking
vitamins, magnesium, or nutritional supplements; or, as a “last resort,” seeing a psy-
chologist (but not a psychiatrist). The reasoning was very similar even in cases of
schizophrenia; the illness was usually attributed to stressful experiences, and treat-
ment was expected to be delivered by a psychologist first and a psychiatrist only later.
The Lima field trial delineated areas of the core CFI that were particularly relevant
in the outpatient setting (Lewis-Fernández et al. 2014). The main results pointed out
that the core CFI had these positive outcomes:
• Strengthening of the provider-patient relationship. Patients felt listened to and

better understood and felt that the doctor’s interest was more genuine and greater
than expected. This, in turn, led to more openness on the patient’s part.
• Detection of and facilitation of a prompt discussion of potential sources of distrust
and prejudice, such as the fact that the patient was from a different ethnic group
than the psychiatrist. It also allowed discreet inquiries about topics as varied as re-
ligious beliefs, bewitchment, psychosomatic symptoms, and personality styles.
• Encouragement of open expression of patients’ views about their disorders and
treatment and of awareness and acceptance of factors such as family, social, and
financial resources that could impact access to care, treatment adherence, and clin-
ical course.
• Elicitation of information to help guide the modality of psychotherapy recom-

mended (individual, couple, or family oriented).
Our experience with the core CFI in the psychiatric outpatient setting showed
that it could be extremely valuable in exploring connections between the cultural as-
pects of the patient’s illness experience and medically unexplained physical symp-
toms (Fiestas-Teque and Vega-Dienstmaier 2012; García-Campayo et al. 2008). This
connection is clearly important in certain cultures, such as those in Latin America or
Africa (Bagayoyo et al. 2013; Gureje et al. 1997), where clinical somatization and re-
lated features are often interpreted following traditional beliefs about health and dis-
ease. Moreover, it is equally relevant to understand the illness experience in any
patient struggling to make sense of persistent symptoms (Kirmayer and Sartorius
2009).
Urban and Rural Community Health Centers

In addition to traditional health centers, the practice of community psychiatry encom-
passes settings such as halfway houses, ambulatory home services, rehabilitation cen-
ters, and other venues. These services emphasize coverage of a geographical area or
territory, continuity of care, multidisciplinary health care teams, and active commu-
nity participation. In fact, they have been recognized as the antecedents of current ef-
forts to develop integrated or collaborative care (Diez-Canseco et al. 2014). In these
contexts, cultural aspects of the individual and his or her social surroundings may
transcend other considerations, and the cultural competence of the psychiatrist and
other providers becomes a sine qua non of clinical practice.
Cultural competence—the knowledge, familiarity, and understanding of the way of
life of communities or minority populations and the skills needed to deal with all
kinds of patients—is a compelling requirement in settings that are more closely situ-
ated “inside the community” (Kirmayer 2012). Instruments such as the CFI can facil-
itate work in such settings, both by identifying important contextual aspects of the
patient’s experience and by engaging other community members, for example,
through the use of the CFI–Informant Version with people in the patient’s entourage
or, when appropriate, members of the larger community. When the focus is on pa-
tients’ lives in the community context, issues such as cultural identity and explana-
tory models, as well as help-seeking patterns, levels of functioning, and family or
social support, may become paramount in the evaluation process.
Certain aspects of urban and rural community settings can add to the complexity
of the cultural assessment. A wide range of behaviors are seen in the community that
ordinarily may not reach clinical attention. For instance, phenomena usually de-
scribed as “hallucinations” may be more prevalent and regarded as normal by differ-
ent ethnic and cultural groups, particularly those strongly influenced by religious
beliefs. Similarly, paranoid ideation may be seen more frequently among groups vic-
timized by systematic persecution and discrimination. If contextual factors are ne-
glected in the evaluation of community populations, the result may be erroneous
diagnoses and deleterious treatments, an example of an undue pathologization of ev-
eryday behaviors (Alarcón et al. 1999).
In community settings, an important assessment step may involve gathering data,

through the CFI, from relatives, community leaders, and other important people in
the patient’s everyday life. This is illustrated by the following vignette.
Case Vignette 3
A traveling clinical team working in a rural village in Peru’s mountains was asked to
visit a family home to assess the grandmother, who was showing depressive symptoms
and possibly mild cognitive deterioration. Judging from the modest appearance of the
home, the style of dress of two accompanying adolescent grandchildren, and the fam-
ily’s ethnoracial complexion, the team assumed that the family was culturally “tradi-
tional” and started to explore common cultural beliefs in the community (including
bewitchment, or brujería) to use the information later in the psychoeducation process.
During the second home visit, however, the team discovered that several family mem-
bers who worked outside the village had been visiting frequently and had become the
most consistent source of support for the grandmother. Most importantly, the family
had adopted urban, Western-based views about her mood problems. Identifying the ex-
planatory models used by those involved in the patient’s care was essential to devising
an appropriate treatment plan.
This vignette illustrates the dilemmas of stereotyping and of assuming cultural

homogeneity even in remote communities. It is evident that had the CFI been avail-
able to the team, direct questioning of the patient and key family members about
help-seeking patterns, explanatory models, and specific contacts with family support
resources could have situated the mood symptoms and the cognitive manifestations
in a more accurate context. The CFI postulates the exploration of local meanings of
symptoms and behaviors and of the role of family members; this is especially valu-
able in rural communities not easily reachable by conventional health care services
(Kirmayer et al. 2014). Such perspective also points to the potential value of using the
CFI and other resources in combination with new communication technologies in
telemedicine and telepsychiatry (Cotton et al. 2014).
Technical Aspects of CFI Applicability

in Different Settings
Consideration of the role of culture in psychiatric conditions faces two potential problems
that are critically opposed to each other: overvaluation and undervaluation. Overvaluation
attempts to explain every symptom or clinical manifestation as a product of culture,
whereas undervaluation excludes culture as an important source of contributing factors in
the production and interpretation of unusual behaviors and psychopathology (Commit-
tee on Cultural Psychiatry 2002). Determining when and how to incorporate and vali-
date cultural data as pathogenic and pathoplastic factors in clinical phenomena is a
challenge that the use of the CFI can help clinicians successfully address.
The CFI can be used by nonpsychiatrist health professionals trained to perform
multifaceted roles. This is the case, for example, with advanced practice psychiatric
nurses (or clinical nursing specialists), who, as documented by Fung et al. (2014), can
perform relevant cultural assessment functions as part of psychosocial interventions
and the development of partnerships with non–mental health service providers. In

a study by Dawber (2013), nurses and midwives who engaged in a process-focused
CL psychiatric training group reported a positive impact on clinical practice, self-
awareness, and resilience.
A potential misuse of cultural information during patient evaluation is stereotyp-
ing—the tendency to view all people belonging to a group as similar in their cultural
beliefs and practices. In every community or population, there are wide individual
variations due to biological, psychological, and environmental factors. Rather than
reproducing stereotypes, the CFI can help clarify this variation. Although some pa-
tients may perceive certain CFI topics or questions as intrusive, most welcome the cli-
nician’s interest in their perspectives and the details of their lifeworld. However,
patient concerns about intrusiveness should not be dismissed but rather should be
met with discrete and opportune formulation of the CFI questions and clear explana-
tions as to their potential relevance to the patient’s care.
One challenge to the applicability of the CFI in many clinical settings is the length
of time it requires to complete. Each setting has its particular dynamics (in which cul-
tural factors also play an important role), but one shared aspect is that the time allotted
for a cultural evaluation in CL, emergency, or outpatient departments may not be lon-
ger than 15 or 20 minutes. Depending on the complexity of the case, the core CFI itself
may require from 20 to 60 minutes. A practical response to these time constraints could
be to administer the CFI only in cases in which useful and relevant findings could be
expected or to use only a few CFI questions or components (Caballero-Martínez 2009).
The use of the CFI may be especially indicated when there are culturally based pro-
vider-patient relationship issues; a history of poor adherence; definite ethnic, socioeco-
nomic, or religious discrepancies between patient's and provider's illness
representations or treatment expectations; specific indications for psychotherapy; or
significant problems in differential diagnosis.
In several of the settings discussed in this subchapter, a significant problem (not
exclusive to psychiatry) is the distrust by patients and families of government and
other official agencies. The nature of psychiatric symptoms and conditions, particu-
larly their culturally based features, may intensify these feelings of distrust and lead
to rejection of services when patients feel their traditional perspectives about health
and disease, religion, and communal life are threatened or neglected. The CFI can
help clarify these concerns and address them by opening up a collaborative discus-
sion of diagnostic and treatment expectations.
Conclusion
Table 4–5 summarizes some distinguishing characteristics of the different clinical set-
tings reviewed in this subchapter. The table outlines some of the environmental as-
pects of each setting, the diagnoses of patients more commonly seen in them, and the
core CFI sections that may need greater emphasis in the evaluation process to arrive
at a more cogent diagnosis and treatment plan. Further research is needed to examine
the adaptation of various CFI components to different settings and to refine the in-
strument so that it can more fully realize its promise.
TABLE 4–5. Characteristics of different clinical settings relevant to the use of

the core Cultural Formulation Interview (CFI)
Environmental Main core CFI

Setting characteristics Main diagnoses sections
Emergency Quick-paced, “chaotic” Psychomotor agitation Cause, context, and

departments multidisciplinary Psychotic episodes support
interactions Suicidal behaviors Past and current help-
Overt socioeconomic Psychiatric complica- seeking patterns
diversity tions of medical con-
ditions
Drug or alcohol intoxi-
cations
Cultural concepts of
distress
Consultation- Nonpsychiatric units Psychiatric complica- Cause, context, and
liaison services Less common psychiat- tions of medical or support
ric occurrences surgical conditions Past and current help-
Well-delineated consul- Psychiatric comorbidi- seeking patterns
tation rules ties Clinician-patient rela-
Depressive and anxiety tionship
disorders
Outpatient Regularly scheduled Mood disorders Cultural identity
clinics referrals and time Anxiety disorders Cultural definition of
assignments Personality disorders the problem
Independent assess- First-episode psychoses Cause, context, and
ments support
Mild to moderate Past and current help-
severity levels seeking patterns
Urban and rural Minority or immigrant Depressive and anxiety Cultural definition of
community patients disorders the problem
health centers Cultural diversity Somatoform disorders Cause, context, and
Socioeconomic homo- Family or interpersonal support
geneity conflicts Self-coping activities
Moderate sense of Clinician-patient rela-
urgency tionship
KEY CLINICAL POINTS

• Clinicians' awareness of the influence of culture on every patient, type of clinical
encounter, and service setting is a basic ingredient of a comprehensive diagnostic
evaluation.
• The clinical setting of a psychiatric evaluation can play a culturally decisive role if fac-
tors such as physical environment, types and assignments of professional and ancil-
lary staff, and institutional norms and procedures are taken into account as a
background of dynamic interactions between clinicians and patients and their families.
• The core Cultural Formulation Interview (CFI) is relevant for work in emergency de-
partments because it can help assess complex situations, as well as clarify the
cause and context of the clinical condition, past help seeking, current treatment ex-
pectations, and sources of support.
• Patients seen in outpatient settings and in urban and rural community health cen-
ters may benefit from use of the CFI to explore cultural identity and cultural defini-
tion of the clinical problem, including sociodemographic characteristics, illness
severity levels, and perceived sense of urgency.
Questions
1. What factors must be taken into account when applying the CFI in different
clinical settings?
2. What are two of the main consequences of misusing cultural information in

different clinical settings?
3. What kinds of cultural elements can affect the presentation and management
of psychiatric conditions in emergency department, consultation-liaison, out-
patient, and urban and rural community health settings?
4. What are the main psychiatric diagnoses with significant cultural implications
that can be seen in the different clinical settings mentioned above?
5. What are some of the challenges that need to be overcome in order to imple-
ment the CFI in each type of clinical setting?
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American Psychiatric Publishing, 2004
Administrative Perspectives on
the Implementation and Use of
the Cultural Formulation Interview
In this subchapter, we discuss administrative perspectives on the imple-

mentation and use of the DSM-5 (American Psychiatric Association 2013) Cultural
Formulation Interview (CFI). It may seem unusual to include a section on administra-
tive perspectives when presenting a new assessment tool such as the CFI. However,
there are always administrative issues and changes that need to be considered in at-
tempts to successfully implement a new procedure or protocol in any organizational
setting, from smaller practices to midsize agencies and large institutions. Lack of at-
tention to administrative issues and operational needs at every organizational level
may result in poor uptake, fidelity, integration, and outcomes. In the sections that fol-
low, we address 1) organizational purpose and need, 2) use and benefits, 3) imple-
mentation strategies, and 4) implementation challenges and potential solutions.
Organizational Purpose and Need

Cultural competence in health care provision is increasingly a necessity rather than
an option or choice in practice. Cultural competence operates at all levels of health
care delivery, from that of patient-provider interaction to the levels of health care or-
ganizations, service systems, and society. The focus in this subchapter is on the role
of the CFI in promoting the concrete application of organizational cultural compe-
tence.
In thinking about organizational cultural competence, it is useful to review some fun-
damental concepts, such as culture, cultural competence, cultural humility, culturally compe-
tent system of care, and organizational cultural competence, which are defined in Table 4–6.
Cultural competence is relevant to all institutions, not only those in which the patient
population is composed of immigrants or those who speak a different language; more-
over, to be effective, principles of cultural competence must be integrated systemwide
(Aggarwal et al. 2013). To support organizational and practitioner integration, the U.S.
Department of Health and Human Services developed the National Standards for Cul-
224
Administrative Perspectives on the Implementation and Use of the CFI 225
TABLE 4–6. Fundamental concepts for cultural competency
Concept Definition
Culture “Systems of knowledge, concepts, rules, and practices that are learned and
transmitted across generations...includes language, religion and spiritu-
ality, family structures, life-cycle stages, ceremonial rituals, and customs,
as well as moral and legal systems” (American Psychiatric Association
2013, p. 749)
Cultural compe- “A set of congruent behaviors, attitudes, and policies that come together in
tence a system, agency, or among professionals and enables...[it]...to work
effectively in cross-cultural situations” (Cross et al. 1989, p. 13)
Cultural humility Commitment to self-evaluation and self-critique and development of self-
awareness and a respectful attitude toward diverse points of view
(abstracted from Tervalon and Murray-García 1998, p. 117)
Culturally com- A system that “acknowledges and incorporates—at all levels—the impor-
petent system tance of culture, the assessment of cross-cultural relations, vigilance
of care towards the dynamics that result from cultural differences, the expansion
of cultural knowledge, and the adaptation of services to meet culturally
unique needs” (Cross et al. 1989, p. iv)
Organizational A systemic perspective of cultural competence that is operationalized at
cultural com- the meso (institutional and programmatic) level (abstracted from Fung et
petence al. 2012, p. 167)
turally and Linguistically Appropriate Services in Health and Health Care (U.S. Depart-
ment of Health and Human Services, Office of Minority Health 2010, revised 2013).
Implementation of the CFI can help address several of these 15 standards.
To achieve cultural competence, an institution needs to make diversity a core value
and engage in regular self-assessment, while enhancing staff cultural knowledge and
maintaining a culturally humble stance. Cultural competence practices must be inte-
grated in the culture of the work setting and the institution itself. This integration in-
volves an ongoing process of learning, reflection, and repeated self-assessment,
framed from the starting point of cultural humility—the recognition of the limits of
one’s own cultural understanding. To aid in culturally competent psychiatric assess-
ment, the DSM-5 Cross-Cultural Issues Subgroup developed an updated Outline for
Cultural Formulation (OCF) and the CFI, a specific set of assessment questions that
can be used to apply the OCF in routine practice. Richmond Area Multi-Services
(RAMS), an organization located in San Francisco, California, served as one of the
field trial sites. Throughout this subchapter, we draw examples from the experience of
RAMS in administering the core CFI to illustrate how the process of implementing the
CFI can promote organizational cultural competence.
Founded in 1974, RAMS is a not-for-profit mental health agency with a mission to ad-
vocate for and provide community-based, culturally competent, and consumer-guided
comprehensive services to meet the behavioral health, social, residential, vocational, and
educational needs of the diverse San Francisco community, with a special focus on Asian
and Pacific Islander Americans and Russian speakers, who represent a substantial pro-
portion of the local population. Many of the agency’s patients are recent immigrants and
refugees in need of bilingual, bicultural mental health services. RAMS approaches cul-
tural competency as a highly collaborative and ongoing process by which the principles
are consistently applied and integrated into the development and implementation of pol-
icies and procedures (e.g., satisfaction surveys, client council, personnel recruitment and
performance evaluation, training and supervision). Annually, RAMS serves about 18,000
adults, children, youth, and families, most of whom have extremely limited resources and
receive public health benefits. The agency offers a wide array of mental health and social
services in 30 languages at over 90 locations (including outpatient programs, schools, and
child care sites). For the CFI study, RAMS engaged Cantonese-speaking Chinese Ameri-
can clients and clinicians, translating the core CFI questions into Chinese.
Use and Benefits

Psychiatric practice in cross-cultural settings faces several challenges, including prac-
titioner-patient differences in ethnicity and culture that affect the therapeutic relation-
ship. This, in turn, may lead to increased risk for bias and stereotyping, impeding the
clinician’s understanding of the patient and hindering a meaningful and effective
clinical relationship (Scarpinati Rosso and Bäärnhielm 2012). In institutions striving
to be culturally competent, administrators and supervisors seek ways to promote cul-
tural competence and humility by engaging the institution’s workforce in the process
and by utilizing approaches and tools tailored for this purpose. Administrators in
particular may be responsible for devising effective implementation processes and
procedures to promote cultural competence. Implementation of the DSM-IV (Ameri-
can Psychiatric Association 1994) OCF was hampered because it relied heavily on the
preexisting cultural knowledge, skills, and intuitions of the individual practitioner
and/or group leadership (department/unit management). With the development of
the DSM-5 CFI, an organization’s or practitioner’s ability to integrate culturally com-
petent assessment has been significantly enhanced because the CFI offers 1) standard-
ization of a qualitative method of assessment, 2) scalability and accessibility, and 3) a
focus on information that can contribute to clinically relevant results and outcomes.
Standardization
The CFI operationalizes the OCF for clinicians by offering a structured format with a
specific process and practical approach by which a patient assessment and/or inter-
view can proceed, using field-tested wording and sequencing of questions. In many
practice settings, clinicians are presented with an assessment form that is composed
primarily of symptom checklists and/or rating scales. Clinicians may then use a wide
variety of approaches to solicit the requisite information from patients. The CFI en-
ables an organization and practitioner to standardize this qualitative aspect of patient
interviewing, in a culturally competent manner, using a sequence of questions that
foster a respectful, engaging, and thoughtful process to explore relevant issues.
Practitioners must assess cultural nuances with each patient because these nuances
vary from person to person and affect how a patient thinks about mental health, well-
ness, and illness (Warren 2013). This assessment process can be difficult to carry out,
however. In a qualitative study by Kai et al. (2007) on how health professionals experi-
ence and perceive their work, findings highlighted considerable uncertainty and dis-
empowerment among practitioners in responding to the needs of patients of different
ethnicities from their own; the study suggests interventions to empower professionals,
which include shifting away from a cultural expertise model toward greater emphasis
on each patient as an individual by soliciting patients’ own viewpoints and experience.
The CFI is not tailored to specific cultures but instead provides a generic format for cul-
tural evaluation and therefore may help an organization support its practitioners in
working with individuals and families from diverse and emerging communities and
varying cultural experiences, potentially resulting in improved clinician satisfaction
and morale. The standardization of assessment will likely increase diagnostic accuracy,
treatment planning, and care coordination, leading to shorter treatments and savings
for the organization (e.g., the health care plan may accommodate more patients) and
the patient (e.g., lower out-of-pocket expenses).
Scalability and Accessibility

The CFI process is scalable in its training methodologies and accessible by organiza-
tions and practitioners. In addition to being included in DSM-5, the CFI components
are provided in the appendixes in this handbook and are available free of charge from
the American Psychiatric Association Web site (http://www.psychiatry.org/practice/
dsm/dsm5/online-assessment-measures). The CFI can be implemented by organiza-
tions of any size and/or by specific units or departments. It may also be used by a wide
range of practitioners (e.g., psychiatrists, psychiatric nurses, social workers, therapists,
case managers, cultural brokers) with a range of clinical experiences (e.g., graduate
students or seasoned clinicians; practitioners working with less familiar patient popu-
lations). The CFI does not require extensive training and knowledge to be used as an
assessment tool. In RAMS’s experience of training in the core CFI, many practitioners
indicated that the questions were straightforward and familiar and could easily be in-
tegrated into their current practice. Practitioners were also open to using the core CFI
because RAMS’s organizational culture embodies and integrates, at all levels, cultural
competence principles and practices. For example, RAMS conducts an organizational
assessment of its integration of culturally and linguistically appropriate services and
uses it to develop agency and programmatic objectives. Discussions about how to
work with culturally diverse populations regularly take place both during formal ses-
sions (e.g., weekly didactic trainings) and informally among practitioners. Our expe-
rience with the DSM-5 field trial is that the core CFI’s comprehensive approach to
engaging the patient and the sequencing of the questions prompt the patient to offer
the information needed by the clinician to complete a typical diagnostic assessment.
The design of the CFI supports RAMS’s ability to easily integrate the CFI into many of
its programs and departments, including its outpatient clinic, school-based services,
welfare-to-work counseling program, and residential facility.
The CFI can be used for cultural competence training with residents in several medi-
cal fields (e.g., psychiatry, internal medicine, family medicine) as well as with interns and
other trainees in various mental health disciplines. At RAMS, cultural competence train-
ing is conducted regularly throughout the year. For example, with graduate-level interns
the training includes an overview of cultural competence concepts, an introduction to the
OCF, and instruction on the CFI and how to incorporate it into the assessment process.
We find the CFI to be a practical way of developing the clinical skills of trainees new to
the health care field by teaching them to apply the theories and conceptual frameworks
they learned in school. Being easy to teach facilitates its uptake by personnel from many
disciplines. The CFI offers a common framework for the treatment team to foster commu-
nication between providers. As Dinh et al. (2012) reported on the use of the OCF, the par-
ent framework for the CFI, “Case conceptualization starts out as multidisciplinary but
becomes interdisciplinary, through the recognition, utilization and integration of the ex-
pertise and perspectives of the various professions represented in the group” (p. 13).
Information Relevant for Clinical Outcomes

The core CFI can be used at the beginning of the clinical encounter, as well as at any stage
of treatment, because its application leads to a better understanding than standard clinical
interviews of how the patient is embedded in a particular sociocultural context, which, in
turn, may enhance the patient-practitioner relationship (Rohlof et al. 2009). The CFI
seems to elicit the patient’s own narrative of the situation to a greater extent than do
symptom checklists. The CFI helps the clinician explore the patients’ identity and under-
stand how culture shapes everyday practices such as diet, living arrangements, emo-
tional expressions, and decision-making processes (Aggarwal et al. 2013).
Comprehensive, patient-centered assessment such as the CFI is expected to enhance prac-
titioner-patient rapport and communication, diagnostic accuracy, treatment planning,
treatment adherence, treatment outcome, and patient satisfaction.
Implementation Strategies
When introducing new tools and/or practices, administrators can consider the imple-
mentation strategy in terms of three main phases: 1) planning, including identifica-
tion of goals and potential challenges (e.g., need for training to enhance culturally
competent care and identification of potential obstacles) and selection of desired
course of action (e.g., specific systemic changes and interventions, and methods of
implementation); 2) implementation, including communication, allocation of roles,
and mobilization of resources; and 3) evaluation, comprising review of effectiveness,
benefits, and modification of the integration process as needed (Table 4–7).
Planning
To apply these strategic phases to the integration of the CFI in a health care system or
organization, the administrator can first consider the organization’s history, current
cultural competence, and past ways of handling comparable changes in practice or
procedures. Questions such as these may be useful: Has the organization recently un-
dergone many procedural changes? What concerns have practitioners expressed
about former or existing assessment tools? What is the awareness and level of com-
TABLE 4–7. Cultural Formulation Interview (CFI) implementation checklist
Task Stage(s)
Assess organizational culture and readiness Planning

Engage and identify implementation team and resources Planning
Achieve buy-in Planning
Develop implementation plan (e.g., training, time line, policy, workflow Planning
adjustments)
Integrate into workflow Implementation
Provide training Implementation
Roll out (possibly initially as a pilot) Implementation
Communicate bidirectionally (e.g., reporting, feedback, disseminating Implementation,
data) evaluation
Make adjustments to implementation plan, as needed Implementation,
evaluation
Monitor and review for quality assurance Evaluation
Provide ongoing support and additional training for sustained CFI use Evaluation
mitment toward cultural competence initiatives shown by the organization, the

funder(s), and the policymakers? What experience have the practitioners had with
the application of the OCF? By anticipating challenges or obstacles, the administrator
can more thoughtfully develop an appropriate and effective implementation plan.
A key component of planning and implementation is communication. It is impor-
tant to approach this component horizontally by engaging the staff in ongoing discus-
sions and collaboration rather than vertically by having administrators dictate use of
the new protocol. Also, administrators must be aware of their own attitudes and level
of enthusiasm about the implementation of the CFI so they can respond appropriately
to feedback. Practitioners must be able to ask questions and have an open dialogue.
Administrators and middle managers—including department/program directors,
managers, and supervisors—must ensure that there is time to discuss the usefulness
of the CFI, what did or did not work during its initial application and what challenges
emerged in using the CFI to gather patient information. As a result, practitioners will
be more receptive to hearing the administrator’s presentation of the benefits and
“added value” of CFI. The administrator’s open and flexible stance can positively in-
fluence the effective implementation, fidelity, and sustained use of the CFI.
Along with these efforts to establish communication with practitioners and other pro-
viders, the administrator should also initially engage middle managers in developing the
implementation plan. In RAMS’s experience, there was an initial discussion with super-
visors who provided feedback on the core CFI, focusing on how the tool would be bene-
ficial, how patients might respond, and what would be the potential challenges to its use.
The dialogue led to the development of an implementation plan, taking into account the
identified issues, such as the timing of training and rollout, and potential end-user reac-
tions. Practitioner engagement can also be channeled through the formation of a commit-
tee of key organization members who volunteer to take part in the implementation
process and whose work would be affected by implementation of the CFI (e.g., middle
management and end users such as psychiatrists and social workers). These individuals
can function as intervention “champions” or people to go to when questions arise. Mid-
dle managers can support the messaging of the organizational goals to direct service
practitioners and can provide the day-to-day support needed at the front line by listening
to concerns and addressing any implementation dilemmas as they come up. It is crucial
that middle managers be motivated to use the CFI and be supported by administrators
who solicit their feedback throughout each stage of planning, implementation, and eval-
uation. To support this collaborative effort, the administrator can present the core imple-
mentation goals while granting the committee some flexibility in their application.
Specific committee recommendations could focus on time line, scheduling, enrollment,
and implementation deadlines as well as on scaling the rollout (e.g., which program[s]
should implement it first). An implementation plan should include clear goals (e.g., pro-
cess and outcome objectives) along with identified individuals and groups that are re-
sponsible for different aspects of the process.
It is also important for administration to support the integration of the CFI into ex-
isting clinical workflow and documentation procedures. For instance, how do the
day-to-day logistics need to change to accommodate the use of the CFI? How should
the CFI be integrated into existing documentation systems? Addressing these issues
early on might include streamlining the revision of existing forms to include the do-
mains covered by the CFI, with careful review to prevent duplication of information.
For example, a so-called road map can be developed that illustrates how each core
CFI question may lead to answering particular sections of a required form. Then a
work group can be convened to combine the existing forms and the core CFI into a
single document. At the same time, there should be consideration of how the core CFI
and other CFI components can be incorporated into the management information
systems and other data collection processes.
As part of the planning phase, administrators must also consider staff training
needs and develop a training plan. It may be beneficial to facilitate the CFI training
process by integrating it into existing training and/or staff meeting schedules (e.g.,
by holding the CFI training during a regular seminar). Because the CFI is used to im-
prove the quality and cultural competence of the assessment process, it is more ben-
eficial when used as part of a larger cultural competence and humility standards
framework than when used in isolation. It is important that organizations develop
policies and procedures to integrate cultural competence into everyday practice. For
example, at RAMS, cultural competence principles are integrated as part of the orien-
tation and training curriculum and performance evaluation process.
Implementation
CFI trainings may include role-playing and review opportunities. The usefulness of
the CFI can be illustrated through case conferences, which can show how the infor-
mation gathered can be used for case formulation, which, in turn, can lead to more
accurate diagnosis, identification of the patient’s strengths and need for community
resources, appropriate intervention strategies, and comprehensive treatment plan-
ning. For example, existing case conferences can include the CFI within the presenta-
tion outline and discussion. For middle managers, there can be specific training on
how to integrate the CFI as an educational and training tool and how to support con-
tinued utilization for practitioners. CFI training can offer additional incentives such
as continuing education credits and/or educational training accommodations.
In larger organizations, it may be helpful initially to pilot test the CFI integration with
a smaller group of practitioners before integrating it across the entire department, pro-
gram, or system. Administrators can ask practitioners to volunteer for this pilot testing;
having staff involved in this way may reduce some of the implementation challenges.
Ideally, middle management and/or administrators can be included in the pilot test. Fol-
lowing this initiative, the administrator can obtain feedback from all middle managers
and practitioners regarding the benefits and challenges that emerged so as to make fur-
ther suggestions for integration. With each instance of feedback and/or suggestion, there
needs to be consistent accountability for addressing any concerns or questions. For exam-
ple, feedback sessions may include meeting notes with action items that indicate individ-
uals responsible for follow-up; at the next meeting, updates in relation to each action item
can be discussed. The administrators, middle managers, and/or practitioners involved
can in turn share their experience with the CFI and its clinical utility, which may further
motivate other practitioners to integrate it into practice.
Evaluation
To evaluate the usefulness of the CFI, administrators can develop feedback mechanisms
such as in-person meetings (with individuals or large or small groups), consultations
with the implementation committee, focused discussions with middle managers, and/or
written evaluation protocols for practitioners and/or patients to complete. For example,
anonymous patient satisfaction surveys can focus on changes in practitioner engage-
ment. Key performance indicators may include, among others, increased rates of patient
engagement following intake/assessment (e.g., higher attendance rates, fewer premature
terminations), improved treatment adherence, improved patient satisfaction, improved
practitioner skills in serving diverse communities (e.g., avoiding misdiagnosis), en-
hanced or adjusted service array, and improved organizational cultural competence.
It is also very helpful to share data with practitioners about the benefits and chal-
lenges of using a new tool. Administrators often develop and implement policies and
then move on to other projects without obtaining staff feedback or even informing staff
of the impact of the new procedures. It is crucial to have follow-up meetings to solicit
feedback from the end users. Feedback should focus on whether the information gath-
ered via the CFI assisted in diagnosis, engagement, care planning, and referral.
Implementation Challenges
and Potential Solutions
When integrating new tools or practices, administrators must remain flexible so as to
cope with unanticipated challenges, while simultaneously anticipating potential ob-
stacles and developing solutions to overcome them. Adjustments to clinical proce-
dures may be needed at all organizational levels (frontline staff to leadership) for a
variety of reasons, including in response to serving an emerging cultural community.

Although the administrative considerations are similar in most settings, they also
vary depending on organization size, culture, and environment (e.g., funding stream,
political climate). Implementation requires paying attention to challenges that
emerge at least at these three levels: 1) overarching policy, funding, and reporting re-
quirements; 2) organizational routines, procedures, and practices within the health
care system and institutions; and 3) practitioner skills, roles, and activities.
Overarching Policy, Funding, and Reporting Requirements

Although there are compelling reasons for developing cultural competence in health
care provision, the health care field is continually beset by increasing demands for
heightened scrutiny, compliance with regulations, rigorous reporting and documenta-
tion, and patient satisfaction. There are federal, state, and local government policies
that support enhancement and integration of cultural competence. However, funding
tends to be limited for such efforts, particularly for administrative functions. For exam-
ple, health insurance plans and public benefits programs such as Medicaid tend to re-
imburse for practitioner-patient direct service time but not for expanded
organizational planning and clinician training. As a result, organizations may reallo-
cate and/or seek additional resources. Although the CFI constitutes an investment of
resources (e.g., staff time for training), we at RAMS expect an overall return on invest-
ment through the maximization of effective outcomes. In fact, most of the resources are
needed in the initial implementation stages; once the CFI is fully integrated into the or-
ganization’s routine, substantially fewer resources may be needed because the founda-
tion of the procedures and structure has been established. Policies and funder
requirements may also include specific assessment tools that must be used and/or
mandates relating to the length of time allocated for sessions. However, the core CFI
questions cover many of the same topics evaluated in a routine clinical assessment, al-
beit from a cultural perspective, making it possible to comply with requirements for
existing instruments while still incorporating the CFI. If more information is needed,
the 16-item core CFI can easily be supplemented with additional questions, including
those from the supplementary modules also developed during the DSM-5 process (see
Chapter 3, “Supplementary Modules,” and Appendix C in this handbook).
Organizational Routines, Procedures, and Practices

The organization must consider how implementing the CFI will impact the clinical
workflow and billing practices as well as how to streamline documentation of the in-
formation obtained. It also needs to consider how using the CFI might impact the as-
sessment sessions (e.g., whether the intake appointment duration should increase or
decrease, whether the initial patient chart packet needs to be updated). In our experi-
ence with implementing the core CFI at RAMS, some staff members noted that the
core CFI includes assessment areas they might not otherwise have investigated dur-
ing the interview (e.g., regarding the clinician-patient relationship). As such, the pa-
tient health record forms—whether paper based or electronic—must be reviewed to
ensure that there are sections where the practitioner can note responses to the CFI
questions (e.g., regarding suggested kinds of help). Because the core CFI can easily be
integrated as part of the general intake assessment or treatment planning, billing for
the CFI is streamlined (e.g., when an intake assessment incorporates the CFI, the total
time can be considered assessment billing). The organization should also assess its ca-
pacity to adjust its management information systems accordingly.
The organization must also consider organizational policy issues regarding the ad-
ministration of the CFI: Is CFI usage required by organizational leadership? Do pro-
viders need to adhere strictly to administering the entire set of core CFI questions? If
assessments are collaboratively conducted by a multidisciplinary team, which specific
practitioner would administer the CFI? In addition, the organization needs to consider
training-related questions such as these: Who will coordinate the logistics of the train-
ing (e.g., initial rollout, ongoing training)? Who will conduct the training? How will
competence in CFI be assessed? Moreover, if there are multiple trainers across differ-
ent departments or sectors, other issues arise: How could cross-communication take
place (e.g., shared training experience, consolidated feedback)?
The organization may also need to consider its protocol related to translations. Al-
though CFI translations are forthcoming (e.g., through foreign-language translations of
the full DSM-5), administering the CFI with non-English-speaking patients may present
complications. Field trials were conducted in several countries, supporting the core CFI’s
translatability, ease of use, and applicability across diverse cultures (see Chapter 2, “The
Core and Informant Cultural Formulation Interviews in DSM-5,” and subchapters “Use
of the Cultural Formulation Interview in Different Clinical Settings” and “Application of
the Cultural Formulation Interview in International Settings” in the current chapter). At
the same time, translation may introduce variations in how the questions are interpreted.
For example, RAMS translated the core CFI to written Chinese, but there was ongoing
discussion regarding word choice and phrasing, which are dependent on factors such as
which Chinese language is used (e.g., Cantonese or Mandarin) and emigration area (e.g.,
mainland China or Hong Kong) of the patient. Agency administrators needed to remain
flexible about how to use the translations, so that clinicians and interpreters can use a
translation as a guide rather than adhering strictly to it. Documenting translation difficul-
ties should be part of quality assurance.
Practitioner Skills, Roles, and Activities

As an organization implements the CFI, some clinician ambivalence (e.g., lack of motiva-
tion or buy-in) and/or “comfort in routine” may present in various ways. In RAMS’s ex-
perience, some practitioners indicated that incorporating the core CFI added time to the
existing assessment process. They also noted, however, that the core CFI offered a more
comprehensive patient-centered interview. Some clinicians may view the introduction of
the CFI as suggesting that the organization does not endorse the clinicians’ typical ap-
proach and instead views it as ineffective or not culturally competent. This concern pres-
ents an opportunity for administrators to engage the clinicians, being careful not to reject
their current way of assessing patients. Use of the CFI may be suggested, not required,
while the administrator takes the opportunity to learn what the clinicians’ current assess-
ment approach is and how it is different from or compatible with the CFI.
Clinicians may also express difficulty accommodating to certain patient prefer-

ences and/or addressing resource needs. This can be responded to through supervi-
sion, case conferences, and ongoing training, as well as by developing collaborative
partnerships in the community. Furthermore, in RAMS’s experience, the utilization of
case management and peer support services has been very helpful in dealing with
some resource limitation issues. Of course, better engagement with patients may ini-
tially lead to greater demands for services, and it is important for the system of care
to be prepared to respond appropriately.
Conclusion
Clinically sound and culturally competent service delivery, high standards of care, pa-
tient satisfaction, and clinical and administrative efficiency are important goals in any
health care system and organization. Although implementation of the CFI may require
initial resources, the benefits we are starting to see from its use at RAMS are important
(Table 4–8). The CFI not only can improve our work with patients in meaningful ways but
also can enhance the quality and outcomes of the health care services we deliver.
TABLE 4–8. Lessons learned from implementing the Cultural Formulation

Interview (CFI) at Richmond Area Multi-Services
Lesson Specifics
Organizations must integrate cultural The DSM-5 CFI can contribute to culturally competent
competence practices in order to practice by providing a structured yet flexible assess-
meet the needs of a continually ment framework. The CFI fosters a person-centered
diversifying population. dialogue about a patient’s mental health concerns
experienced in a specific cultural context, which is
expected to lead to more accurate diagnosis and col-
laborative treatment planning.
The CFI offers many potential benefits Benefits include standardization of a qualitative method
at the organizational level. of assessment, scalability in its training methodolo-
gies, accessibility by organizations and practitioners,
and potentially effective results and outcomes.
Implementation strategies should ini- A small group of middle managers and practitioners
tially develop an implementation can develop an initial plan that includes CFI pilot
plan. testing; ongoing training for practitioners and mid-
dle managers; case conferences; and integration
with clinical workflow, documentation, and man-
agement information systems.
The implementation process should be This open process should help in developing feed-
flexible and open to feedback from all back mechanisms and evaluative measures and in
stakeholders. sharing results with practition-ers in order to sup-
port effective integration and fidelity of the CFI.
Implementation challenges will arise Implementation challenges typically involve policy
that can be addressed through a and funding requirements, organizational routines
planning process that includes mul- and procedures, and practitioner skills and roles.
tiple stakeholders.
KEY CLINICAL POINTS

• The DSM-5 Cultural Formulation Interview (CFI) is expected to enhance an orga-
nization’s or clinician’s ability to integrate culturally competent assessment because
the CFI offers 1) standardization of a qualitative method of assessment, 2) scalabil-
ity and accessibility, and 3) a focus on information that can contribute to clinically
relevant results and outcomes.
• When introducing new tools and/or practices, administrators can consider the im-
plementation strategy in terms of three main phases: 1) planning, 2) implementa-
tion, and 3) evaluation.
• Key components of the implementation strategy are communication and remaining
flexible to cope with both anticipated and unanticipated challenges.
Questions
1. What are the main phases and key components of an implementation strategy?
2. What communication approaches can help integrate the CFI into a health care
system or organization?
3. How could the DSM-5 CFI enhance an organization’s or clinician’s ability to

integrate culturally competent assessment into routine practice?
4. What issues are to be considered when integrating the CFI into a health care
system or organization?
5. What key performance indicators may be used to evaluate the usefulness of

the CFI?
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Suggested Readings
Burke WW: Organization Change: Theory and Practice, 4th Edition (Foundations for Organi-
zational Science). Thousand Oaks, CA, Sage, 2013
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Advancing Health Equity at Every Point of Contact. Rockville, MD, U.S. Department of
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Accessed August 25, 2014.
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Application of the
Cultural Formulation Interview
in International Settings
Hans Rohlof, M.D.
Rhodah Mwangi, B.A.
Mental health care faces the global challenge of integrating awareness of cul-
ture and context into psychiatric diagnosis and treatment planning. In this subchap-
ter, we discuss whether the Outline for Cultural Formulation (OCF) and the Cultural
Formulation Interview (CFI) are useful tools for addressing cultural diversity in clin-
ical diagnostic practice outside the United States and Canada. Our discussion is based
on experience in India, Kenya, the Netherlands, and Sweden and other Nordic coun-
tries. These settings were chosen because they are culturally, socially, and geographi-
cally different from each other and all have experience using the OCF and the CFI.
The international usefulness of the CFI can easily be questioned. The OCF and the CFI
are included in a diagnostic system presenting a psychiatric nosology developed in the
United States. The idea that Diagnostic and Statistical Manual (DSM) nosology has uni-
versal validity, when the research supporting it has been based mainly in North America
and Western Europe, has been criticized (Gone and Kirmayer 2010). In most nations,
psychiatric diagnostic practice and documentation have been developed according to the
International Classification of Diseases (ICD), the official international diagnostic system
(World Health Organization 1992). The desk reference edition (American Psychiatric
Association 2013a) of DSM-5 (American Psychiatric Association 2013b) diagnostic cri-
teria has been translated into several languages, but DSM-5, which includes the OCF and
the CFI, is available in fewer languages. Therefore, access to the OCF and the CFI, as well
as to the introductory texts about culture included in DSM-5 and the text about cultural
variation in relation to diagnostic criteria, is restricted.
237
Despite these limitations, clinical experience suggests that the OCF, the core and
informant versions of the CFI, and the CFI supplementary modules can be usefully
and relevantly applied in international settings. These tools offer a valuable person-
centered approach for taking culture and context into account in an individualized
and nonstereotyping way. In this subchapter, we discuss our experience with the OCF
and the CFI in several countries, potential modifications of the CFI for use in interna-
tional settings, and the role that psychiatric practice in other countries may play in
continuing to refine the CFI.
Experiences With the CFI in India

India is the second most populous country on earth, with 1.25 billion inhabitants and
enormous cultural diversity (Datanet India 2014). Health care depends on both free
government health care facilities available to all and private out-of-pocket expenditures
for those who are able to access private health care services. India was the first low- and
middle-income country to implement a national mental health program to decentralize
and deprofessionalize mental health care (Directorate General of Health Services
1982). However, India continues to have a dearth of trained mental health profession-
als, including psychiatrists (only about 4,000 are in the whole country, mostly in urban
areas), clinical psychologists, psychiatric social workers, and psychiatric nurses (less
than 2,000). Indian students use standard Western textbooks during their medical train-
ing, although the students themselves may be deeply rooted in an Indian ethos. Several
leading Indian psychiatrists have described Indian cultural concepts of distress, such as
dhat syndrome and possession states (Gautam and Jain 2010; Malhotra and Wig 1975).
Although Indian educators do emphasize the role of cultural and social issues in diag-
nosis and management, most students find it easier to follow the textbook. ICD-10 is the
official diagnostic system adopted by the Indian government, but textbooks refer to
DSM, so students are also familiar with the DSM system and use it frequently.
Two Indian clinical sites, in New Delhi and Pune, were part of the DSM-5 field
trial of the core CFI. Our experience at the New Delhi site is described in this subchap-
ter. The clinical setting was the Post-Graduate Institute of Medical Education and Re-
search (PGIMER), at the Dr. Ram Manohar Lohia Hospital, one of the oldest free
tertiary-care teaching institutions run by the government. The department of psychi-
atry is housed in a general hospital psychiatry unit serving metropolitan New Delhi
as well as nearby North Indian states. The unit treats 200–250 outpatients per day and
had more than 10,000 new patients in 2012 and 2013. Faculty members participate in
the teaching and academic activities of Guru Gobind Singh Indraprastha University
in Delhi, with which PGIMER is affiliated. The department has a strong tradition of
research in major mental disorders and associated social and psychological issues
(Post-Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lo-
hia Hospital 2014), which led to its inclusion in the CFI field trial.
Patients presenting to the New Delhi site hail from several North Indian states and
have widely varying cultures and languages. People from the hills, tribes, and urban
and rural areas in and around Delhi, as well as people from South Indian states, pre-
sent every day. Although Hinduism is the dominant religion and Hindi the dominant
Application of the CFI in International Settings 239
language, other religions are practiced and languages spoken by at least half the pa-
tients admitted. Belief in Indian systems of medicine, such as Ayurveda, Unani, ho-
meopathy, faith healing, and home remedies, runs high. The view is prevalent that
modern medical treatment is synonymous with medications, and patients tend to be
skeptical of modern nonmedical interventions. Stigmatization of mental illness is fre-
quent. Although expression of mental symptoms in physical terms is common among
rural or less psychologically sophisticated populations, the urban or more educated
people verbalize their mental distress in psychological terms. The educational back-
ground of the mental health personnel who administered the core CFI is rooted in
Western traditions, textbooks, and scientific paradigms.
Experiences From the CFI Field Trial

The design of the field trial is described in Chapter 2, “The Core and Informant Cul-
tural Formulation Interviews in DSM-5.” Thirteen clinicians at the New Delhi site, in-
cluding psychiatrists, clinical psychologists, and psychiatric social workers, were
trained through two didactic lectures and two interactive workshops. Several clini-
cians also participated in the CFI translation process. Only new outpatient admis-
sions registering for the first time were enrolled in the study. Their diagnoses were not
known beforehand and included psychoses, drug abuse, childhood problems, and
“minor” psychiatric disorders, such as anxiety, mild depression, and relationship is-
sues. Both patients and clinicians provided quantitative and qualitative feedback on
the core CFI–enhanced diagnostic interview, and investigators also gathered the im-
pressions of several colleagues who participated in the trial.
Participants
The consent process and CFI process were novel for participants, many of whom had
come from remote areas. All 68 participants in the field trial appreciated the clinician’s
efforts to obtain more information through the CFI, which emphasized that their cul-
tural background was important for their ailments. All said that the questions were
helpful and that the doctor gave a lot of time and “asked everything.” The vast majority
of patients used the word good to describe the experience, and they were impressed
with the clinician’s behavior. However, some found it difficult to comprehend ques-
tions on their “cultural background” because it was something they had never consid-
ered or been asked about. Some felt that they should have been asked about their
economic situation, relations with their spouse, or childhood experiences. The time and
opportunity for free communication during the CFI was most valued. Most patients re-
ported that a great burden had been taken off their minds, because “everything had
been asked.” They felt that the clinician showed caring involvement or relatedness (or
apnapan, which is Hindi for intimacy, affinity, kinship) by eliciting cultural details.
Those who were advised to seek psychotherapy and nonmedication treatments such as
yoga were even more appreciative. They felt that the doctor had gotten to the root of
their problem by not merely focusing on medications and that they would get well. Be-
cause of the detailed interview process, they could be frank so that the doctor under-
stood them better and this would help their recovery. However, the majority said that
they had come to the hospital because of their illness and expected medication.
Because this was their first visit to the clinic, patients had difficulty articulating what
help they wanted. Almost all felt that a clinician’s cultural background mattered little
because the clinicians were professionals and were “supposed to know” about the cor-
rect treatment. Notably, they felt that the information from the CFI would significantly
improve mental health care not only for themselves but for patients in general.
Clinicians
Participating clinicians felt that the CFI was most useful for developing rapport, clar-
ifying the patient’s psychosocial background, and obtaining information on issues af-
fecting illness expression. They said that it significantly improved communication,
“bonding,” and the clinician-patient relationship and that it was helpful in compre-
hensively eliciting all symptoms, thus aiding in diagnosis, treatment planning, and
adherence. Even issues of daily living could be better investigated. Some said that the
CFI yielded information about the patient’s economic status. The CFI was described
as not being helpful in cases of drug abuse or withdrawal syndromes, as well as with
uncooperative or disorganized patients.
Most clinicians felt that the initial questions on the nature of the patient’s concerns
were most informative and immediately established rapport and that the questions
on clinician background and “how can we help” also helped improve communica-
tion. However, some thought that the original question on the patient-clinician rela-
tionship included in the field trial version of the core CFI inquired unnecessarily
about clinician background and made participants uncomfortable. This question was
later revised for the DSM-5 version.
Summary of Indian Experience

The importance of culture in psychiatric evaluation and the potential usefulness of the
core CFI were recognized by both clinicians and patients participating in the field trial.
The overall response was positive. The core CFI seemed to facilitate the inclusion of pa-
tients’ language of symptom expression in the diagnostic process and the involvement of
patients as active partners in treatment planning by attending to their cultural concerns.
When clinicians took the time to patiently ask about cultural and personal issues, impor-
tant facts emerged. Overall, professional participants were most sensitive to how cultural
background shapes illness expression and treatment adherence. Department members
became more aware of local symptom expression, and senior members’ teaching of the
importance of cultural factors in management grew more emphatic. The result of the field
trial was greater emphasis on the Indian experience and expertise in teaching. However,
the time needed for the core CFI is likely to constrain its general use. Perhaps, as some cli-
nicians suggested, only the most relevant questions can be woven into the general psy-
chiatric history–taking process. To be useful for regular clinical use in Indian contexts, the
core CFI will need to be shortened significantly.
Experiences With the CFI in Kenya

Kenya, with a population of 43 million people, is one of the poorest countries in the
world, ranked 144th out of 177 countries in the human development index. Nairobi,
the country’s capital, is home to one of the largest slum areas in Africa: Kibera, a vast
shanty city with 170,000 to 1 million inhabitants (Central Intelligence Agency 2013).
Provision of health services in Kenya is predominantly government funded. It is
broadly structured into six levels: national referral hospitals (level 6), provincial gen-
eral hospitals (level 5), district hospitals (level 4), health centers (level 3), dispensa-
ries (level 2), and volunteer community health workers (level 1) (Republic of Kenya
Ministry of Health 2005). Mental health care remains extremely limited in terms of
infrastructure, staffing, and finances. Specialist care is largely delivered by psychiat-
ric nurses in outpatient clinics at the district level and in inpatient units and outpa-
tient clinics at the provincial level. Psychiatrists, on the other hand, provide
specialized care in the national referral hospitals at Mathari National Teaching and
Referral Hospital, Kenyatta National Hospital/University of Nairobi, and recently
the Moi Teaching and Referral Hospital. The total number of mental health hospital
beds for the entire Kenyan population was 1,114 in 2009, a bed-to-population ratio
of approximately 1:200,000 (In2MentalHealth 2013).
Kenya has a training program for psychiatrists at the University of Nairobi; at least
six new psychiatrists graduate per year. There are currently about 80 Kenyan psychia-
trists; however, most are sequestered in urban centers, with about a quarter (21 of 80)
working in education. Another quarter live and work outside the country. Effectively,
this means that outside of Nairobi, the psychiatrist-to-population ratio is 1:3,000,000–
5,000,000. Compounding this extreme dearth of psychiatrists is the fact that of the 500
trained psychiatric nurses, only 250 are currently deployed in psychiatry. Seventy are
deployed to Mathari National Teaching and Referral Hospital, leaving 180 nurses to
work in the districts and provinces. The result is that there is less than one psychiatric
nurse per district. Many of the rest have retired, died, left the country, or gone to work
for nongovernmental organizations. The future is as gloomy as the present because the
number of new applicants for mental health nurse training is declining.
Local Need for Cultural Awareness

The indigenous Kenyan population consists of approximately 42 tribes or ethnic
groups. Despite their cultural diversity, the various groups’ cultural perceptions
about the causes of mental illness are quite similar. The vast majority believe that
mental illnesses are caused by supernatural powers such as evil spirits. Many think
that those who develop mental disorders do so to atone for sins committed against
ancestors or as a result of being bewitched (Kiima et al. 2004). Kenyans who have ad-
opted Christianity and Islam have abandoned some of these traditional cultural be-
liefs. However, some sects within the Christian faith, especially among Protestants,
believe in faith healing. These sects attract some psychiatric patients, especially those
whose mental illnesses are colored by religious experiences. Usually, Muslim patients
are taken to their sheikhs; these faith healers often use the cultural attitudes toward
mental illness prevalent in their communities to offer spiritual intervention through
prayer (Kiima et al. 2004).
The culture-sensitive nature of psychiatric phenomenology has been explored by
several authors. In a hospital-based study of psychiatrically ill African immigrants in
a London hospital, Ndetei (1988) noted that paranoia, religious phenomenology, and
hallucinations (in particular, auditory hallucinations and first-rank symptoms of

schizophrenia) do not necessarily have the same clinical significance in various cul-
tural groups. Many Africans when ill seek not only treatment but an explanation for
their affliction and guidance toward spiritual well-being (Offiong 1999). They may
engage in Western treatment to cure the illness but then enlist the aid of a traditional
healer to seek an explanation for the cause of the illness. For many, health is not
merely the absence of disease; it signifies peace with the ancestors and spirits (Lambo
1962). In Kenya, this practice cuts across all cultural groups regardless of educational
status or position in society (Odhalo 1962; Otsyula 1973). The health-related actions,
beliefs, traditions, and ways of thinking of Kenyans and other Africans can be seen to
follow local explanatory models and notions of illness causality. This is evident in the
tendency to attribute misfortune or disease to the actions of witches or evil people
and to react with paranoid ideation to certain threatening situations (Ndetei 1988).
These examples inform the need for culture-tailored diagnostic tools such as the CFI.
Experiences From the CFI Field Trial

At the Kenyan site of the field trial, the core CFI was administered to 30 patients in
an outpatient psychiatric clinic in Nairobi. All of the patients were adult indigenous
Kenyans who had been referred for psychiatric management. Patients’ CFI inter-
views were recorded and analyzed qualitatively. Two main findings emerged: 1) the
core CFI helped improve clinicians’ understanding of the patients’ conditions, and
2) patients reported feeling that they had expressed themselves better. These find-
ings were noted especially for patients being evaluated for psychotic illnesses. The
following case vignette illustrates this point.
Case Vignette
Simon, a 37-year-old man from a large coastal city, presented with a 2-month history of con-
stant low mood, anhedonia, and “unusual” behavior that included singing loudly and
shouting at night. After reassuring him that the goal was to understand his specific prob-
lem, experience, and ideas and that there were no wrong or right answers, the interviewer
asked what problems or concerns brought him to the clinic. Simon replied that he was fine
until he lost his job. He then began to display behavior that he insisted was not abnormal
but that his relatives perceived to be “unusual,” and they referred him to a traditional
healer. When asked what he thought was the cause of his problem, Simon said that he felt
he was being tormented by evil spirits. On further probing, he attributed his predicament
to family conflicts involving property and to the fact that he came from a minority ethnic
community in coastal Kenya. He said that his relatives and siblings had contributed to his
condition because they sent the evil spirits to him. He also said that what helped him cope
with his condition was praying to God and watching music videos.
Use of the core CFI enabled further probing of Simon’s cultural belief system, resulting
in a diagnosis of depression and not paranoid schizophrenia. It is important to appreciate
that in many communities in Kenya, any apparent bad luck that befalls someone (e.g., the
loss of a job) will tend to be attributed to perceived enemies’ use of black magic and evil
spirits. The apparent persecutory delusions reported by this patient might have been mis-
taken for symptoms of psychosis if they were not understood within the patient’s sociocul-
tural context. The core CFI was useful in obtaining information about the context and the
meaning of the patient’s symptoms and concerns, which, combined with the interviewer’s
background knowledge of the societal norms, helped clarify the diagnosis.
Summary of Kenyan Experience

In Kenya, implementation of the core CFI started among clinicians working in re-
search. Because Kenya is officially an English-speaking country, the original English
version of the core CFI could be used by clinicians. However, a majority of Kenyans
do not use English as their first language or as the primary language of communica-
tion. We translated the core CFI to Kiswahili, the national language. The diversity of
languages in a multilingual society such as Kenya, however, poses considerable dif-
ficulty in implementing this tool, because Kiswahili is still a second language to many
Kenyans. Nevertheless, the core CFI has gained considerable traction, especially be-
cause Kenya was among the countries that participated in the CFI field trial.
Because of its inclusion in DSM-5, the CFI has been integrated into the curricu-
lum at Kenya’s only psychiatric training institution, the University of Nairobi. The
DSM-IV (American Psychiatric Association 1994) OCF had been used extensively in
training in this institution, which eased the introduction of the CFI as an integral part
of training. This process is gaining momentum because the CFI is now a compulsory
part of training for graduate students specializing in psychiatry. With additional
funding to develop appropriate teaching materials, the use of the CFI could pene-
trate into daily clinical practice through its adoption in continuing medical educa-
tion to train practitioners in mental health care in outpatient clinics and in primary
care or even psychiatric units in any of the other national psychiatric hospitals.
Experiences With the CFI in the Netherlands

The Netherlands is a country of 17 million people, of whom about 1 million are Mus-
lim. Since the 1960s, the ethnic diversity of the Dutch population has grown enor-
mously. The number of people from a foreign background, first and second
generation, is currently about 20% of the population and is expected to grow to 30%
by 2060 (Stoeldraijer and Garssen 2011). In the west of the country, where 7 million
people live close together in the so-called City of Holland, foreign-born individuals
are becoming the majority of the inhabitants.
These demographic shifts have important repercussions for mental health care. The
proportion of immigrants in the mental health care system, which before 1990 was
lower than the percentage of immigrants in the general population, has gradually in-
creased to an equal percentage, although some groups are seen mainly in emergency
departments or forensic settings (Dieperink et al. 2007). Recognition of the need for
more cultural awareness has increased in response to studies showing that poor com-
munication with patients from a different cultural background leads to less effective
treatment, premature treatment discontinuation, and poor adherence (Blom et al. 2010;
Fassaert et al. 2010). Large mental health institutions, mainly in the west of the country,
have started to show interest in more culturally competent care for migrants.
Mental health care in the Netherlands is well developed, with universally avail-
able outpatient services, inpatient services, and other services such as day clinics, fos-
ter homes for chronic psychiatric patients, and day activity centers. DSM is used as
the standard diagnostic system. In 2008, the financial structure of mental health care
was completely changed, with payment transferred from government-funded health

insurance to private health insurance companies. The purpose of the switch was to
reduce costs and improve efficiency through competition. This has resulted in a more
diverse system, in which different regional care providers compete with local care
providers. For the individual patient, this change has resulted in more freedom of
choice. However, the general costs of mental health care have increased substantially,
and the government is trying to raise some barriers to mental health care use. A rou-
tine outcome monitoring system requires caregivers to monitor changes in symptoms
and functioning and to provide outcome data to the health insurance companies.
Experiences With the CFI Field Trial

Three centers in the Netherlands took part in the DSM-5 CFI field trial: a specialized
clinic for refugees, a typical mental health institution, and a psychotrauma clinic. Cli-
nicians were generally satisfied with the feasibility and acceptability of the version of
the core CFI used in the field trial. They were more satisfied with its impact on im-
proving contact with the patient than with its usefulness for diagnosis and treatment
planning. Patients viewed the core CFI more positively than did clinicians, particu-
larly in terms of its potential clinical utility, but were somewhat less satisfied with the
length of the interview and its clarity. Some questions were considered unclear or too
similar to other questions. Discussions by the international research group led to
changes in the final version of the core CFI for DSM-5. In addition, some of the most
experienced clinicians found the structure of the core CFI overly constraining. To ad-
dress this concern, the final version of the core CFI notes that the questions should be
regarded as examples that need not be followed verbatim as long as the content of
each question is examined.
It is worth noting that the core CFI was useful for working with native Dutch pa-
tients as well as migrants. For example, when asked about belonging to a certain
group, one Dutch person responded, “My group is the group of veterans. I only feel
at ease in the company of other veterans. I have noticed that you have a veterans pro-
gram in your clinic. I only accept other veterans in my company, and I hope that all
the therapists will have a veteran background too.” A woman who appeared to be of
Dutch origin remarked, “I’ve lived in the Netherlands for 50 years, but I still feel my-
self East Indian.” She came from the former colony of the Dutch East Indies, now In-
donesia. People born there, who are often of mixed ethnic background, are not
considered immigrants in the Netherlands but, nevertheless, have their own culture
with strong family bonds, distinctive food, and Asian ways of handling difficult emo-
tions by maintaining equanimity; Dutch clinicians not from their background some-
times find it difficult to diagnose the presence of depressed mood because of their
usual smiling demeanor.
Summary of Dutch Experience

Researchers and clinicians in the Netherlands were pioneers in the implementation
of the DSM-IV OCF, prior to the development of the CFI. In the late 1990s, a group of
Dutch clinicians began to use the DSM-IV OCF and prepared a book in Dutch with
chapters on theory and case vignettes (Borra et al. 2002). The concluding chapter
noted that the OCF needed further operationalization. To that end, a cultural inter-
view based on the DSM-IV OCF was developed and used in the clinic to get a better
understanding of refugees, who are sometimes culturally very distant from their
caregivers (Rohlof et al. 2002). The interview was well tolerated by patients and
yielded excellent information about their cultural backgrounds but generally took
about 90 minutes to complete (Rohlof and Ghane 2003); hence, there were attempts
to reduce the number of questions. An abbreviated cultural interview was devel-
oped, which required about half the time to administer. Patients showed better ac-
ceptance of the shorter version, and the information gathered was comparable to that
obtained with the longer interview (Groen and Laban 2011). Further refinements and
applications of this work were carried out, both in psychiatry and general health care
and in clinical practice and education, resulting in a book in Dutch describing the
various cultural interviews and their applications, including in forensic and child
psychiatry settings (van Dijk et al. 2012). In the Netherlands, the original cultural in-
terview (the Rohlof version) and the abbreviated cultural interview (the Groen ver-
sion) based on the DSM-IV OCF have been widely used in the training of psychiatric
residents (in the national training module), clinical psychologists, social psychiatric
nurses, nurse-practitioners, and general practitioners (Bruggeman and Busser 2012).
Implementation of these cultural interviews in education has been a success, but
their routine use in clinical practice has proven more difficult. The Dutch experience
with disseminating and implementing the local cultural interviews serves as a useful
precedent for the CFI; many of the same barriers as well as principal uses and set-
tings of initial uptake apply to implementation of the CFI.
Experiences From Sweden and Other

Nordic Countries
Sweden and other Nordic countries (Denmark, Norway, and Finland) were relatively
culturally homogeneous until World War II, when immigration of laborers and refu-
gees started to increase the cultural diversity of Nordic countries. At present, 15% of
the Swedish population of 9.6 million is foreign born, and first- and second-generation
immigrants make up 20.1% of the population; 53% of the immigrants are from non-
European countries (Statistics Sweden 2013). Migration has also transformed other
Nordic countries, although the percentages of foreign-born immigrants in these other
countries are lower than in Sweden: 8.1% of the Danish population of 5.6 million
(Danmarks Statistik 2013), 10.8% of the Norwegian population of 4.9 million (Vasi-
leyva 2011), and 4.3% of the Finnish population of 5.4 million (Vasileyva 2011).
Sweden and other Nordic countries have tax-funded health care systems that pro-
vide equal rights to care for migrants who have been granted a residency permit. For
asylum seekers, undocumented migrants, and uninsured European Union citizens,
there are restrictions governing access to care. In Sweden, as in other European Union
countries, health care disparities between native-born inhabitants and migrants in-
crease the vulnerability of migrants to poor mental health (Rechel et al. 2013). Despite
equal rights to care, barriers to mental health treatment for migrants include poor flu-
ency in Nordic languages, stigmatization, limited knowledge of the health care sys-
tem, and a lack of cultural sensitivity in the mental health care system.
ICD-10 is the official national diagnostic system of the Nordic countries. In clinical
care, however, DSM is sometimes used in parallel with ICD. Moreover, DSM is often
used in research, education, and training and has a substantial impact on professional
and public discussions on mental health and mental health care. Attention to cultural
variations in ICD-10 is limited. Regional versions of ICD-10 from China, Japan, Cuba,
and Latin America represent attempts to adapt the nosology to local cultural and so-
cial realities (Mezzich et al. 2001). The ICD model, with regional geographical adap-
tations, is not helpful in addressing cultural awareness regarding psychiatric care in
the Nordic countries. This limitation has promoted interest in DSM-IV and DSM-5,
which address culture in the core definition of mental disorder, culture-related issues
in relation to diagnostic criteria, the OCF, and (in DSM-5) the CFI as a practical diag-
nostic tool for taking culture into account.
Local Need for Cultural Awareness

Few clinical service models in Sweden address cultural aspects of mental illness and
treatment. This situation persists despite the fact that some efforts have been made to
address cultural aspects of care with interpreters, in clinics for traumatized refugees,
and in various development projects. However, the concerns about culture have not
been enough to cope with the diversity of needs. The clinical challenge in addressing
culture and context in psychiatric diagnosis has directed attention to the OCF, first in
DSM-IV and now in DSM-5. The clinical contexts of other Nordic countries share var-
ious similarities with the Swedish situation.
Experiences With the DSM-IV OCF

There were no Swedish sites in the CFI field trial; however, Swedish clinicians and re-
searchers have been at the forefront of developing a standardized interview for the
OCF. A Swedish interview guide for how to use the DSM-IV OCF was prepared to
facilitate its clinical use (Bäärnhielm et al. 2007). This guide, which is quite similar to
the core CFI and the supplementary modules in DSM-5, was evaluated in a multiple-
case study with immigrant and refugee patients, most of whom came from the Mid-
dle East, at an outpatient clinic for nonpsychotic disorders (Scarpinati Rosso and
Bäärnhielm 2012). Patients’ narratives were transcribed and analyzed. Results
showed that all the narratives were solidly grounded in their everyday lives, high-
lighting the importance of contextualizing symptoms to aid clinical understanding.
The narrative format of the OCF facilitated interviewers’ use of open-ended questions
to probe the contextual details of patients’ experience (Bäärnhielm and Scarpinati
Rosso 2009). In this study, an interview operationalizing the OCF was conducted after
the ordinary clinical psychiatric diagnostic evaluation. Its use led to a revision of psy-
chiatric disorder diagnostic groupings for 13 of the 23 patients (56%) (Bäärnhielm et
al. 2014). Most of the changes involved identifying missed cases of anxiety disorders
and posttraumatic stress disorder, but some of the changes resulted from revisions of
specific anxiety diagnoses and from reassessing a misdiagnosis of posttraumatic

stress disorder. In a different study, cultural analysis based on the DSM-IV OCF was
carried out with 20 women at a substance abuse outpatient clinic in Sweden (DeMa-
rinis et al. 2009). The cultural assessment revealed that these patients constructed
their identity around alcohol use, developing elaborate drinking rituals and behav-
iors related to consumption, with implications for service delivery and intervention.
Summary of Nordic Experience

In Sweden, clinical implementation of the DSM-IV OCF started with clinicians work-
ing in marginalized, multicultural communities. As diversity increased nationwide,
interest in cultural formulation expanded to include a broader segment of the mental
health care system. A key factor in this wider interest was the inclusion of the core CFI
in DSM-5, which will be translated into Swedish and made available to all free of
charge by the local publisher. Recent psychiatric textbooks in Swedish include infor-
mation about the CFI. To support clinical use of the Cultural Formulation approach
in the greater Stockholm area, terms to document social and cultural information are
included in the shared information technology system for medical records
(www.transkulturelltcentrum.se/vara-kunskapsomraden/transkulturell-psykiatri/
journalforing-i-takecare/).
In Stockholm, information about the OCF and CFI is also included in guidelines
for care and on official psychiatric Web sites. Experiences implementing the CFI in
Sweden indicate the importance of combining clinical application with training and
consultative support. The ethnographic approach of the CFI, which involves eliciting
contextual information through open-ended questions, can be somewhat unfamiliar
for clinicians, because much current diagnostic interviewing has become narrowly
symptom focused. Interpreting a patient’s narrative involves a process of translating
from the patient’s system of meaning to a medical framework. To use the CFI in a flex-
ible way, creating a natural narrative flow, it is important that clinicians understand
the purpose of the questions. This facilitates the reformulation of questions to ensure
that they are comprehensible to the patient, as well as probing for clarification and
elaboration.
There is also interest in the CFI in the other Nordic countries. The Swedish inter-
view guide was translated into Norwegian and Finnish, and a Danish guide was also
developed (Østerskov 2011). Clinical implementation of the CFI in the Nordic coun-
tries will require its translation into local languages. Although initially only the diag-
nostic criteria of DSM-5 and not the whole text were published in Nordic languages,
the CFI and some other assessment measures will be translated into Swedish.
The Transcultural Center of the Stockholm County Council initiated training in the
DSM-IV OCF in 2003. Currently, in Sweden, standard training in the use of DSM-5 and
in transcultural psychiatry is starting to incorporate the CFI. In Norway, the National
Norwegian Center for Minority Health Research has organized several training
events on the DSM-IV OCF, and the CFI is included in transcultural training activities
during psychiatric residency. In Copenhagen, training for mental health professionals
has begun on the use of the Danish interview guide.
Conclusion
Our experience in four distinct cultural settings suggests that the OCF and CFI sub-
stantially improve awareness of culture and context internationally in an individual-
ized nonstereotyping way in psychiatric diagnostic practice. The CFI represents a
fundamental paradigm shift in psychiatric nosology, highlighting social and cultural
influences on psychiatric phenomenology. By integrating a medical anthropological
framework, the CFI provides a richer background for diagnosis. It is important to em-
phasize, however, that the use of the CFI requires a flexible approach that is tailored
to each patient’s peculiarities rather than a verbatim reading of the questions to the
patient. The use of the CFI does not in any way replace the traditional tools and skills
useful for understanding each patient.
For implementation of the CFI in non-English-speaking countries, translations
into local languages are necessary, including the development of local training mate-
rials. To support clinical implementation, there is a need for research on the contribu-
tion of the CFI to diagnostic validity and to improving care in different cultural
settings. More information on how patients understand the various domains and
questions of the CFI can facilitate its use and may contribute to additional clinical im-
pact. On the basis of our experiences, the application of the CFI requires training fol-
lowed by practical support in how to use it. Consultative support in clinical cases can
be valuable. International experiences can contribute to refining the DSM-5 CFI for
diverse populations in different settings. Furthermore, these experiences may also en-
hance knowledge about how culture and context influence mental distress and cop-
ing strategies.
KEY CLINICAL POINTS

• The person-centered, nonstereotyping approach of the Cultural Formulation Inter-
view (CFI) makes it a useful tool for routine clinical practice outside North America
and helps establish trust and rapport between patient and clinician.
• Clinical implementation of the CFI requires local training and ongoing support.
• Clinicians need to understand the meaning and purpose of the CFI questions in
order to adapt them to the local context and individual encounters.
• Clinical use of the CFI in non-English-speaking settings requires its translation into
local languages and potential simplification of some terms.
• Clinical application of the CFI may require health system resource supports and
changes in procedures, such as incorporation into clinical guidelines and medical
record documentation formats.
• International experience can contribute to refining the CFI for diverse populations
in different settings.
Questions
1. How should use of the CFI in routine clinical practice be promoted in interna-
tional settings?
2. What are the pros, cons, and anticipated challenges involved in using the CFI
globally?
3. On the basis of experience with the tool in diverse settings, what procedures,
refinements, and adaptations may be needed to use the CFI internationally?
4. What can international experience contribute to the development of the field

of cultural assessment and cultural psychiatry more generally?
5. How can international use of the CFI contribute to awareness of local symp-
tom expressions?
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CHAPTER 5
Cultural Competence in
Psychiatric Education Using
the Cultural Formulation
Interview
The DSM-5 (American Psychiatric Association 2013a) Cultural Formulation

Interview (CFI) offers medical educators an important opportunity to incorporate
culturally appropriate assessment techniques into existing curricula and teaching ap-
proaches. In this chapter, we review current regulations and published guidelines on
the teaching of culturally appropriate assessment in medical student education, resi-
dent education, and continuing medical education (CME) and suggest how the CFI
can be incorporated into these efforts.
Regulations and Guidelines

on Teaching Cultural Assessment
Education in cultural competence is mandated in medical school and adult psychiatric
residency programs, as well as in some U.S. states for practicing psychiatrists. Training
physicians in cultural competence must start at the level of medical student education,
when basic medical knowledge, skills, and attitudes are developed and solidified. The
Association for American Medical Colleges and the Liaison Committee on Medical Ed-
253
ucation, which provide oversight to medical schools in Canada and the United States,
require cultural competence training as part of the accreditation process. According to
ED-21 and ED-22 of the Standards for Accreditation of Medical Education Programs
Leading to the M.D. Degree (Liaison Committee on Medical Education 2013), medical
students must know that the patient’s ethnic background can influence diagnostic as-
sessment and treatment planning, and they must also develop the ability to self-assess
their levels of bias and stereotyping that may lead to health and mental health dispari-
ties. Training medical students in the use of the CFI can help address both of these objec-
tives (e.g., via core CFI questions 4 and 5 and 15, respectively).
For psychiatric resident education, the Accreditation Council of Graduate Medical
Education (ACGME) incorporates cultural competence principles in its Guidelines for
Six Core Competencies and the Psychiatry Milestone Project (Accreditation Council of
Graduate Medical Education and American Board of Psychiatry and Neurology 2013;
Ling et al. 2013). Residents must see a sufficient variety of patients to be trained in how
to assess different ethnic minority groups. Specifically, new milestones in the profes-
sionalism section guide educators in rating residents’ ability to understand how pa-
tient diversity affects patient care, in developing a care plan that bridges patient and
physician health beliefs, and in discussing their own cultural background and beliefs
and how these affect their patient interactions. For example, the professionalism 1 do-
main in these milestones focuses on “compassion, integrity, respect for others, sensi-
tivity to diverse patient populations” (Accreditation Council of Graduate Medical
Education and American Board of Psychiatry and Neurology 2013). Although the
ACGME does not specifically use the term cultural competence in the milestones, its
principles have been included in the reviews of accreditation criteria.
CME training in cultural competence is required to renew physicians’ licenses in
six states: California, Connecticut, New Jersey, New York, Ohio, and Washington (Na-
tional Consortium for Multicultural Education for Health Professionals 2009). Each
state’s requirement is different. For example, California Assembly Bill 1195 requires all
CME programs to address cultural competence, and New Jersey’s CME requirements
specifically mandate cultural competence education in all medical schools in the state
and a one-time, 6-hour certification in cultural competence for all physicians licensed
in New Jersey. The CFI can help physicians meet these training requirements, espe-
cially via items focusing on cultural illness beliefs (cultural conceptualizations of dis-
tress) and the impact of culture on the doctor-patient relationship (Lewis-Fernández
et al. 2014).
Medical Student Education

Integration
Efforts to implement cultural competence in medical student education typically use an
“additive” approach in which cultural concepts, themes, and perspectives are added to
the general curriculum without significant integration or ongoing reinforcement, com-
monly done by assigning an article or module as an adjunct to the core curriculum. The
results are cultural competence curricula that are fragmented, uncoordinated, and at
Cultural Competence in Psychiatric Education Using the CFI 255
times redundant. Unfortunately, this method of curriculum development marginalizes

the role of cultural competence and limits the opportunity for ongoing curricular devel-
opment and application to clinical practice (Betancourt 2003; Reitmanova 2011).
Recognizing the risk of stereotyping and cultural oversimplification that comes
from focusing only on content descriptions of racial and ethnic differences (Kai et al.
1999), many educators now base their training efforts on multiculturalism, integrat-
ing sexual orientation, migration histories, spirituality, unconscious bias, social de-
terminants of health, and other cultural concepts into a coherent framework. The CFI
offers an excellent approach for designing and implementing a medical student cur-
riculum based on multiculturalism. First, the CFI definition of culture stresses how
cultural views emerge from patients’ engagement with a great diversity of social
groups in their background, not only as a result of their race and ethnicity. Second,
the CFI emphasizes how certain aspects of the person’s background come to the fore
as primary elements of the patient’s identity vary at different times and in different
contexts (e.g., at home, at school). Finally, the CFI can help medical students apply
these complex topics in their day-to-day practice by clarifying clinical interactions
that are culturally unfamiliar to the students. Educators interested in developing
cross-cultural curricula should refer to Table 5-1 for resources.
The CFI can be used as a tool to facilitate cross-cultural communication and nego-
tiation in the patient-doctor relationship. Other tools that assist with these tasks in-
clude commonly taught frameworks such as ETHNIC (Levin et al. 2000) and BELIEF
(Dobbie et al. 2003). The CFI has particular strengths over and above these frame-
works in that it also addresses questions about cultural identity, the therapeutic rela-
tionship, and psychosocial stressors and cultural features of vulnerability and
resilience (social supports).
To ensure uniform application of the CFI for medical students from all specialty
interests, the core CFI questions can be integrated into the standard medical inter-
viewing format. The inclusion of the CFI questions in the standard medical interview
will help medical students obtain richer medical histories while also helping to en-
sure that the patient’s cultural histories are sensitively obtained. Using this format,
the core CFI can be introduced in general medical interviewing courses that are usu-
ally taught in the first year. Cultural competence workshops can then teach students
to develop a framework for interpreting the cultural histories. Clinical clerkships can
help students learn to apply these questions to real patient interviews and clinical as-
sessments and in treatment planning. In Table 5-2, the authors of this chapter propose
a new model, the CFI-Enhanced Medical Interview.
The final three questions (14–16) of the core CFI (see Appendix A in this hand-
book), modified for all specialty contexts, can be used to help medical students facil-
itate the process of shared decision making as they conclude the history-taking
portion of the interview.
Sample Curriculum
At the University of California Davis (UCD) School of Medicine, medical students
progress through a 4-year curriculum titled Teamwork for Professionalism, Ethics,
TABLE 5–1. Resources for medical student education in cultural competence

Curriculum assessment
Tool for Assessing Cultural Competence Training (TACCT; Lie et al. 2008)
Curriculum design
Association of American Medical Colleges: Cultural Competence Education for Medical Stu-
dents. Washington, DC, Association of American Medical Colleges, 2005
Expert Panel on Cultural Competence Education for Students in Medicine and Public Health:
Cultural Competence Education for Students in Medicine and Public Health: Report of an
Expert Panel. Washington, DC, Association of American Medical Colleges and Association
of Schools of Public Health, 2012. Available at: https://www.mededportal.org/download/
303534/data/culturalcompetencereport.pdf. Accessed June 15, 2014.
Curriculum implementation
MedEdPORTAL, www.mededportal.org
Note. TACCT provides validated recommendations for learning objectives organized across five do-
mains of cultural competence for educators who wish to systematically assess and address gaps in their
curriculum. Combined with actual learning modules, such as those found in MedEdPORTAL, on the
American Association of Medical Colleges Web site, TACCT can be a powerful asset for curriculum de-
velopment.
TABLE 5–2. Proposed Cultural Formulation Interview (CFI)–Enhanced

Medical Interview
Standard interview component Resequenced core CFI questionsa
Chief complaint CFI question 1

History of present illness CFI questions 2, 3, 4, 5, 6, 7, 11
Past medical/psychiatric history CFI question 12
Social history CFI questions 8, 9, 10, 13
a
Note. Original numbering scheme retained for reference to core CFI.
and Cultural Competence Enrichment (Team PEACE). Students achieve cultural

competence milestones over the 4 years through small-group exercises, standardized
patient interviews, didactics, and clinical exposures that are embedded in various
courses throughout their education (Table 5–3). Each milestone and its accompanying
learning method build on the prior step, enhancing synergy and reinforcing cultural
competence throughout all years of medical student education. These milestones are
assessed at various intervals through observed standardized patient interviews, self-
assessments, reflective writing, multiple-choice tests, and observation by faculty.
Although efforts to infuse the CFI into the Team PEACE curriculum are just begin-
ning, training in CFI-enhanced medical interviewing will be introduced in the first-
year interviewing course. In medical student year 1 (MS-1), the Team PEACE modules
would address why these questions are asked; in MS-2 through MS-4, the modules
would address how the information obtained from these questions can be used to
render and deliver culturally appropriate assessments and treatment.
TABLE 5–3. Team PEACE cultural competence curriculum thread
School Learning milestones:

year medical students will be able to Learning method
Mid MS-1 1. Describe culture and its components in broad and SGDs with trigger
inclusive terms videos
2. Describe their own cultural background and belief
systems
3. Appreciate the meaning of health and illness from
different perspectives
End MS-1 4. Describe health disparities and sociocultural, SGDs with trigger
genetic, and epidemiologic factors that may con- videos
tribute to these disparities Project Implicit Hidden
5. Describe the impact of language on health status Bias Tests (Project
and health care Implicit, https://
6. Appreciate conscious and unconscious bias in implicit.harvard.edu/
themselves and its impact on health care delivery implicit/)
Large group didactic
7. Work collaboratively with peers across cultural
sessions
groups
Mid MS-2 8. Describe and begin to implement approaches to SGDs

understanding and working effectively with Culturally diverse
patients from culturally diverse backgrounds patient panel
End MS-2 9. Describe the components, challenges, and benefits Large group demon-
of the effective use of a health care interpreter stration
Small-group standard-
ized patient scenarios
Mid MS-3 10. Develop rapport and effectively communicate with Clinical exposure and
patients across various cultural groups didactics
End MS-3 11. Demonstrate incorporation of cultural beliefs, prac- Clinical exposure and
tices, and supports into assessment and treatment didactics
planning
12. Demonstrate effective use of a health care inter-
preter in actual clinical care
End MS-4 13. Apply knowledge of health care disparities and 1-month clinical course
sociocultural, genetic, and epidemiologic factors to chosen by MS-4 train-
care of patient populations across various cultural ees
backgrounds
Note. MS=medical school; SGDs=small-group discussions; Team PEACE=Teamwork for Professional-
ism, Ethics, and Cultural Competence Enrichment.
Adult Psychiatric Resident Education

Residency curricula in cultural competence emphasize training in multiple areas, in-
cluding culture-general skills, such as how to conduct a cultural assessment with a
patient from any culture; culture-specific knowledge, such as idioms of distress com-
mon in particular groups; and fostering attitudes that support culturally appropriate
assessment and treatment. “Guidelines for Training in Cultural Psychiatry” (Kir-

mayer et al. 2012) is a comprehensive guide to curriculum design originating from the
Canadian Psychiatric Association that predates the release of the CFI. Many of its ma-
jor components can now be taught using the CFI. For example, the Canadian guide-
lines emphasize the importance of 1) awareness of the clinician’s own identity and
relationship to patients from diverse backgrounds (the subject of core CFI question
16); 2) knowledge of how cultural context and background influence help seeking,
coping, adaptations to illness, treatment response, healing, recovery, and well-being
(core CFI questions 11, 12, 14, and 15); and 3) skill building in cultural formulation
and treatment negotiation (the CFI as a whole). Other topics included in the Canadian
guidelines and other curricula are presented in Table 5–4.
The backbone of any cultural psychiatry curriculum is clinical experience with di-
verse patients and supervision by culturally trained faculty (American Psychiatric
Association 2013b). Teaching methods for cultural competence in adult psychiatric
residency programs rely on a variety of approaches, as noted by a qualitative study
in which 20 cultural psychiatry instructors in adult residency programs across the
United States were interviewed (Hansen et al. 2012). These approaches include lec-
tures, reflective experiences, role-playing, field trips for observation, small-group dis-
cussions, ethnographic writing, films, culturally themed meals, ethnic group–based
didactics, case formulation using the DSM-IV (American Psychiatric Association
1994) Outline for Cultural Formulation (OCF), and modeling interviewing tech-
niques by faculty (American Psychiatric Association 2013b; Lim 2015). As a rule, the
resident progresses through a series of stages: expanding cultural awareness (enhanc-
ing sensitivity, reducing bias), acquiring cultural knowledge, achieving cultural
skills, and managing cultural encounters (Campinha-Bacote 1994). Experiencing in-
creased awareness of blind spots, bias, and stereotyping improves openness toward
cultural material and enhances understanding of differences. Small-group discussion
after experiential exercises evoking bias and stereotyping can result in a powerful ex-
perience of self-reflection that facilitates changes in attitudes (Crenshaw et al. 2011;
Guzder and Rousseau 2013). Teaching methods should be adapted to the specific
needs of the residency program from the variety of modalities described above, and
they should be aligned with proven teaching techniques, such as incorporating adult
learning principles and including experiential exercises and small-group discussions.
Moreover, the courses should include comprehensive evaluations with formative and
summative feedback for trainees.
Many curricula in cultural psychiatry focus on specific topics, such as cultural mi-
nority groups, women, sexual orientation, elderly people, children, and religion and
spirituality (Al-Mateen et al. 2011; American Psychiatric Association 2013b). These
curricula usefully identify thematic areas for discussion, such as during seminars for
residents and/or fellows. However, if this is the extent of the cultural curriculum, the
topic-based approach runs the risk of replacing old stereotypes with new ones. A
skills-based approach can avoid group-based teaching (e.g., the black patient, the fe-
male patient). The goal is to teach clinicians how to use their experience as normative
data for the interpretation of the patient’s illness experience (Aggarwal and
Rohrbaugh 2011). The CFI as a whole offers an excellent new approach for fostering
TABLE 5–4. Cultural curriculum recommendations for adult psychiatry

residency programs
Knowledge Skills
Definition of culture, general concepts Clinical interviewing with the CFI to elicit
Stigma, stereotypes, and unconscious bias cultural concepts of distress
Health and mental health disparities Ethnographic writing exercises
Structural systems and public health Patient-centered care using the CFI
Ethnopsychopharmacology Case formulation using the DSM-IV OCF
Berry et al. (1986) model of acculturation Training in the use of interpreters at specialty
Religion, spirituality clinics and use of cultural brokers
Sexual orientation (LGBTQ) Identification and management of interethnic
and intraethnic transference and counter-
Women’s issues
transference
Cultural concepts of distress
Institutional infrastructure
Attitude
Grand rounds focused on culture
Experiential learning
Lecture and discussion on how policies affect
Movies and articles evoking stereotyping health and mental health and how to inter-
and bias vene
Videos of role-plays for self-assessment Visits to local community
Exercises to instill cultural humility as a life- Recruitment of diverse residents and faculty
long process
Cultural case conferences
Diversity training (cultural identity explora-
Integration of cultural content across courses
tion)
Minority fellowships for residents and junior
faculty
Note. CFI=Cultural Formulation Interview; LGBTQ=lesbian-gay-bisexual-transgender-queer;
OCF=Outline for Cultural Formulation.
skill development. The core CFI, the CFI–Informant Version, and the 12 supplemen-
tary modules can guide trainees in eliciting crucial information on the specific needs
of the patient, by covering topics related to cultural identity, social networks, and cer-
tain social determinants of health. The 16 core CFI questions can be a basic tool to un-
derstand how health disparities affect individuals and perhaps to formulate ways to
intervene. Introduction of the CFI–Informant Version and the 12 supplementary
modules in advanced courses may foster deeper understanding of cultural issues and
give meaning and support for the ongoing use of the CFI.
Programs will need to decide at which point in the training to introduce any of the
components of the CFI. We recommend using the CFI early on after creating a cultur-
ally receptive environment through supportive discussions of bias and stereotyping,
followed by self-reflection activities. The CFI should not be taught as a rigid set of
questions; after clearly explaining the intent of each question, trainees should be en-
couraged to create their own versions of the CFI questions that they can use comfort-
ably. Programs should consider creating or modifying intake forms to include
cultural formulation questions and providing fields in the database to collect such in-
formation, as well as adding cultural formulation to the resident's evaluation form.
Other factors influencing the preparation of cultural curricula include the patient
population being served, the availability of culturally competent faculty, the level of
administration support, and the input of a core committee of instructors to ensure the
curriculum’s sustainability (Lewis-Fernández 2013). The importance of institutional
support and the value of having a member of the residency training committee advo-
cate for cultural education programs cannot be overemphasized (American Psychiat-
ric Association 2013b). A major challenge to the implementation of cultural curricula
is the recruitment of qualified supervisors with interest, experience, and knowledge
in teaching cultural psychiatry. Departments of psychiatry should expand their efforts
to recruit culturally trained faculty by utilizing resources such as graduates of the
American Psychiatric Association/Substance Abuse and Mental Health Services Ad-
ministration (APA/SAMHSA) Minority Fellowship and other training programs and
by encouraging an interest in cultural psychiatry among their own residents and fac-
ulty. For example, the department could nominate a resident to be an APA/SAMHSA
Minority Fellow to develop curricula for the program (Lim et al. 2008).
Obviously, the CFI alone will not be sufficient to build a curriculum. Other com-
ponents, such as cultural grand rounds, CME programs, and case conferences, with
oversight by a committee dedicated to the cultural curriculum, will need to be in-
cluded. It is crucial that the medical school and residency program administration
convey the importance of cultural competence by prioritizing it among competing
centralized didactics.
Model Curricula in Cultural Psychiatry

In 2010, the American Association of Directors of Psychiatric Residency Training spon-
sored a national call for model curricula in cultural psychiatry aimed at adult psychiatric
residency programs. Two model curricula were chosen, one from New York University
(NYU), which follows a yearlong course format, and another from UCD, which has a lon-
gitudinal design, with seminars throughout all 4 years of residency training. The NYU
course, offered during PGY-3, is called Culture and Psychiatry. Modules address three
main goals: cultural competence, cultural humility, and cultural critiques. One module,
for example, focuses on the patient-clinician interaction and includes the following sub-
topics: perceiving the other, perceiving the self, and working through cultural transfer-
ence and countertransference (Hansen et al. 2010).
The UCD cultural psychiatry curriculum exposes trainees to an ethnically diverse
faculty and population of patients (Lim et al. 2010) and is supported by department
administration, which sustains the development of the longitudinal curriculum. A
safe environment is developed to help trainees practice self-reflection and learn skills
for clinical assessments using the OCF and CFI. The use of the CFI through a range of
clinical tasks is encouraged, including psychiatric intakes, psychotherapy, and case
presentations.
Other Examples of Adult Psychiatric Residency Curricula

Two other programs that deserve mention for their cultural curricula are those at the
University of Toronto and Yale University. At the University of Toronto, an integra-
tive curriculum has been developed that focuses on generic cultural competencies, in-
cluding the application of the CFI and psychotherapeutic and pharmacological
interventions with diverse cultural groups, as well as training in the use of interpret-
ers and specific cultural competencies, such as eliciting cultural concepts of distress
and illness explanatory models (Fung et al. 2008). The development process for the
University of Toronto curriculum included a needs assessment and a survey of resi-
dents’ interests, followed by the creation of a faculty working group, a standing steer-
ing committee, and a faculty retreat to discuss the proposed changes. The cultural
psychiatric curriculum at Yale relies on residents as teachers, is incorporated into cen-
tralized didactics, and is overseen by a committee of residents and faculty. The focus
is on person-centered care, health disparities, experiential learning, and videos of res-
idents role-playing the OCF and CFI, followed by self-reflection (Díaz et al. 2015).
Continuing Medical Education

for Practicing Clinicians
The U.S. Office of Minority Health has developed federal regulations requiring health
care organizations to provide culturally and linguistically appropriate services (U.S.
Department of Health and Human Services, Office of Minority Health 2013). These
standards link systemic cultural competence to quality/performance improvement
activities. Both live and Web-based CME courses have been developed to help pro-
viders comply with the standards. Several of these courses are described in the psy-
chiatric literature, but so far, published reports have not included the CFI. For
example, one live course based on the DSM-IV OCF focuses on cross-cultural diagno-
sis and treatment planning (Lim 2015); in 2014, the course incorporated the CFI for
the first time along with the OCF. The Annual Summer Program in Cultural Psychia-
try at McGill University (www.mcgill.ca/tcpsych) offers CME training in cultural
competence that is grounded in the social sciences (see source reference included in
American Psychiatric Association 2013b).
Web-based CME courses make it easier to reach busy clinicians and clinicians in
isolated rural settings and to address time and economic constraints. Web-based re-
sources have grown exponentially over the last two decades (Díaz et al. 2012; Quality
Interactions 2014; U.S. Department of Health and Human Services, Office of Minority
Health 2011), but it is unknown to what extent they have incorporated training in the
CFI. Yale’s CME course uses the OCF as a guide. Web sites and videos dedicated to
cultural competence are available through the U.S. Office of Minority Health (U.S.
Department of Health and Human Services, Office of Minority Health 2011); educa-
tional institutions such as the University of Pennsylvania, Drexel University, and the
University of California, San Francisco; health insurance companies; and health care
information providers such as Medscape and Quality Interactions (Quality Interac-
tions 2014). These programs aim to develop knowledge and skills to enhance the cul-
tural sensitivity of treatment providers, leading to greater self-reflection, critical
thinking, and cultural humility in practitioners. CME Web sites also attempt to ad-
dress a relatively neglected area: strategies to address health disparities (Like 2011).
In the future, CME courses can be developed based on the CFI, ranging from a sin-
gle course focused on the core CFI to advanced courses that facilitate more compre-
hensive training based on the core CFI plus the supplementary modules. Expanding
state medical boards’ requirements for cultural competence training would likely
help increase CME course attendance. Live or Web site training should include use of
the CFI and should encourage participants to either videotape their patient encoun-
ters using the CFI or have a qualified proctor sit with the clinician during an interview
in which the CFI is used.
Conclusion
The publication of the CFI in DSM-5 presents medical educators with the opportunity
to teach medical students, psychiatric residents, and practicing psychiatrists how to
collect clinical information in order to develop a cultural formulation. Learning how
to use the CFI is a key skill that supplements any teaching regarding cultural concepts
of distress, differing health beliefs and values, and treatment expectations. Medical
students can learn to include the CFI questions in their routine interviews. Psychiatric
residents can use the core CFI, the CFI-Informant Version, and the supplementary
modules to create comprehensive cultural formulations. CME courses can demon-
strate to practicing clinicians how the CFI can help them develop rapport and collab-
orate with patients to create a mutually acceptable, culturally appropriate treatment
plan. Over time, the CFI will become a standard training intervention primarily
aimed at skill building that will be incorporated into most training resources used to
develop cultural competence, including those listed in Table 5–5.
KEY CLINICAL POINTS

• The Cultural Formulation Interview (CFI) can be used for teaching culturally appro-
priate assessment to medical students, psychiatry residents, and practicing clini-
cians through continuing education courses.
• Using the CFI, trainees may be able to learn how to better negotiate treatment
plans with patients because of its patient-centered focus and attention to the pa-
tient’s and social network’s cultural conceptions of distress.
• Using the information elicited from the CFI, clinicians can enlist existing support
systems, reduce the impact of stressors, and bridge the patient’s and clinician’s ex-
planatory models to enhance adherence with treatment recommendations.
TABLE 5–5. Cultural competence training resources for educators

American Psychiatric Association: Resource Document on Cultural Psychiatry as a Specific
Field of Study Relevant to the Assessment and Care of All Patients. Arlington, VA, American
Psychiatric Association, 2013b. Available at: http://www.psychiatry.org/File%20Library/
Learn/Archives/rd2013_CulturalPsychiatry.pdf. Accessed July 14, 2014.
Beamon CJ, Devisetty V, Forcina Hill JM, et al: A Guide to Incorporating Cultural Compe-
tency into Health Professionals’ Education and Training. Washington, DC, National Health
Law Program, 2006. Available at: http://njms.rutgers.edu/culweb/medical/documents/
CulturalCompetencyGuide.pdf. Accessed June 15, 2014.
Betancourt JR, Green AR, Carrillo JE: Cultural Competence in Health Care: Emerging Frame-
works and Practical Approaches. New York, The Commonwealth Fund, October 2002. Available
at: http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf.
California Endowment: A Manager’s Guide to Cultural Competence Education for Health
Care Professionals. Woodland Hills, CA, California Endowment, 2003. Available at: http://
www.calendow.org/uploadedfiles/managers_guide_cultural_competence(1).pdf.
California Endowment: Principles and Recommended Standards for Cultural Competence Edu-
cation of Health Care Professionals. Woodland Hills, CA, California Endowment, 2003. Available
at: http://www.calendow.org/uploadedfiles/principles_standards_cultural_competence.pdf.
California Endowment: Resources in Cultural Competence Education for Health Care
Professionals. Woodland Hills, CA, California Endowment, 2003. Available at: http://
www.calendow.org/uploadedFiles/resources_in_cultural_competence.pdf. Accessed
February 12, 2004.
Comas-Diaz: Multicultural Assessment. Washington, DC, American Psychological Associa-
tion, 2012
Comas-Diaz L, Jacobsen FM: Ethnocultural transference and countertransference in the ther-
apeutic dyad. Am J Orthopsychiatry 61:392–402, 1991
Group for the Advancement of Psychiatry: Cultural Assessment in Clinical Psychiatry. Wash-
ington, DC, American Psychiatric Publishing, 2002
Hays PA: Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy,
2nd Edition. Washington, DC, American Psychological Association, 2008
Kirmayer LJ, Fung K, Rousseau C, et al: Guidelines for training in cultural psychiatry. Can
J Psychiatry 57(insert):1–16, 2012
Lim RF: Clinical Manual of Cultural Psychiatry, 2nd Edition. Washington, DC, American Psy-
chiatric Publishing, 2015
Lu FG: Annotated Bibliography on Cultural Psychiatry and Related Topics. Arlington, VA,
National Alliance on Mental Illness, February 2005. Available at: http://www.nami.org/
Content/ContentGroups/Multicultural_Support1/Fact_Sheets1/
Dr_Lu_Cultural_Bibliography.pdf. Accessed February 19, 2008.
Tseng WS, Strelzer J: Culture and Psychotherapy. Washington, DC, American Psychiatric Pub-
lishing, 2001
Questions
For Educators
1. What are the best methods for teaching the CFI in undergraduate, graduate,
and postgraduate medical education?
2. How do medical educators engage and encourage medical students, residents,

and clinicians in practice to use the CFI?
3. How can educators teach trainees about stereotyping and bias toward ethnic
minorities and discuss concepts such as racism with racially mixed or homo-
geneous audiences?
For Learners
1. How do clinicians best address the impact of cultural health beliefs and prac-
tices on patients’ ways of understanding illness and expectations of care?
2. What are the best methods for teaching culturally appropriate assessment skills?
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CHAPTER 6
Conclusion
The Future of Cultural Formulation
The introduction of the Cultural Formulation Interview (CFI) in DSM-5

(American Psychiatric Association 2013) is a milestone in the development of cultural
psychiatry and, more broadly, of person-centered mental health care. This volume
provides detailed elaboration of the rationale, development, and application of the
cultural formulation in diverse clinical settings. In this concluding chapter, I consider
some directions for the future development of the CFI and of cultural formulation
more generally, in terms of theory, research, and practice.
The Place of Culture in DSM

Recent decades have seen growing recognition in psychiatry of the importance of cul-
ture as the matrix within which people experience, express, and cope with mental
health problems. The introduction of the Outline for Cultural Formulation (OCF) in
DSM-IV (American Psychiatric Association 1994) was a major step in articulating
what aspects of culture and context are relevant to everyday practice in the United
States and other countries.
DSM-III-R (American Psychiatric Association 1987) had only a brief mention of
culture in the introduction. The DSM-IV Work Group on Culture and Diagnosis,
sponsored by the National Institute of Mental Health, made a concerted effort to elab-
orate cultural considerations for many of the disorders in the text (Mezzich et al.
1999). A large group of clinicians and researchers conducted systematic reviews of the
literature on cultural variations in mental disorders and distilled these into lessons
relevant for diagnostic assessment. However, the text was limited to comments on in-
dividual disorders, and no change in the overall structure of diagnostic categories
was possible. Moreover, the basic concern of cultural psychiatry—understanding
267
mental health problems in social context—was somewhat at odds with the aim of the
nosology to describe problems in context-free, abstract, or general terms applicable
in diverse settings (Thomas 2014). Some of the contrasts between DSM and a cul-
tural-contextual approach are summarized in Table 6–1. These are not categorical dif-
ferences but are, rather, shifts in emphasis, and ideally, the cultural perspective
complements and expands the biomedical framework that is implicit in the structure
and focus of DSM.
From the perspective of cultural psychiatry, the most significant innovation in
DSM-IV was the OCF. Unfortunately, over the subsequent decades there was limited
uptake and implementation of the DSM-IV OCF (Kirmayer et al. 2008). One reason
for this limited use may have been the absence of any instruction within DSM-IV on
how to collect the information needed to fill in the outline (Mezzich et al. 2009). The
CFI in DSM-5 directly addresses this gap by giving clinicians a simple protocol to fol-
low to collect basic information relevant to cultural formulation. The hope is that this
will demystify the process of cultural assessment by providing a clear place to start
and suggestions on how to pursue particular lines of inquiry with the supplementary
modules. Further efforts to disseminate information on the CFI through workshops,
publications (including this handbook), and video demonstrations make it likely that
it will be better integrated into clinical training in the years to come.
The CFI is a work in progress. Although it is based on the knowledge of clini-
cians with long experience working in settings with high levels of cultural diversity
in several countries, the hope is that it can continue to be refined and elaborated
through research and clinical and training experiences (Lewis-Fernández et al. 2014).
The American Psychiatric Association has made the CFI freely available online to
encourage its wide distribution (www.psychiatry.org/practice/dsm/dsm5/online-
assessment-measures). In effect, the CFI is a living document that will be modified
with new knowledge. In particular, more needs to be known about how to adapt the
core questions to different settings and types of patients, and there is much room to
refine and add to the supplementary modules to clarify how experts pursue partic-
ular lines of inquiry to gain an understanding of patients’ symptoms, concerns, and
adaptation.
Dilemmas in the Design of the CFI

The development of the CFI involved several important trade-offs between the dy-
namic view of culture and context provided by anthropology and other social sci-
ences and the practical demands and constraints of clinical work. Ethnographic
research can provide extensive descriptions of individual lives and cultural commu-
nities that allow nuanced understanding of the complexities of illness experience, but
this typically requires extended periods of time and access to individuals’ lifeworlds
through participant observation. Clinical work operates under intense constraints of
time and resources and with an urgent mandate to come up with a clear assessment
and intervention plan. Reflecting these constraints, the core CFI presents a limited set
of questions that aim to elicit crucial elements of cultural context in the hopes that this
will improve clinical care; however, it remains unclear how well any brief interview
Conclusion 269
TABLE 6–1. Contrasts between the DSM framing of disorders and a cultural
perspective
Contrast category DSM Cultural perspective
Object of clinical attention Discrete disorders Predicaments

Medical semiotics Symptoms viewed as indices Symptoms viewed as acts of com-
of disorders munication or behaviors embed-
ded in cultural systems of
meaning
Location of problem Within patient Within social situation or context
Locus of causal factors, Individual Family or social system
sources of resilience
Interventions Psychopharmacology, indi- Systemic individual, family, com-
vidual psychotherapy munity, social network inter-
ventions
Outcomes Symptom reduction Recovery defined in terms of per-
sonal and communal values
such as the CFI can achieve an adequate level of understanding of particular patients,
problems, or contexts.
Social science research also points out that the ways in which culture, race, and
ethnicity are conceptualized in psychiatry reflect particular notions of identity. DSM
is a U.S. publication, produced by the American Psychiatric Association, but it has
global reach. Hence, examining some of the cultural assumptions built into DSM is
important for its cultural adaptation and for understanding how the CFI can be max-
imally relevant in other countries or contexts. In U.S. psychiatry, culture has generally
been taken to refer to ethnicity or racialized identities, which are often grouped to-
gether into five ethnoracial blocs: African American, American Indian and Alaska
Native, Asian and Pacific Islander, Latino, and white (or Caucasian) (Good et al.
2011). These are extremely heterogeneous groups that reflect the history of U.S. mi-
gration and identity politics, organized by the imposition of labels in the U.S. Census.
As such, these labels do not apply well in other countries and, in fact, fail to capture
the diversity of identities important to people in the United States. Unfortunately,
some approaches to cultural competence training tend to reify these categories by
presenting capsule summaries or profiles of the blocs or other ethnoracial groups,
hence minimizing internal variation or the complex ways in which individuals make
use of cultural identities and resources.
The CFI makes an important break with this tradition of overgeneralizing or es-
sentializing cultural identity by inquiring into identity on an individual basis. It thus
encourages the clinician to think about identity as a personal project, in which the in-
dividual has at hand multiple potential sources of identity, which can be used in com-
plex and idiosyncratic ways to construct a sense of self, belonging, and social
positioning. The CFI allows for the possibility that facets of identity can be built
around language, religion or spirituality, occupation, or indeed any aspect of family,
group, or collective history. This open-ended approach should allow clinicians to
work with the constantly changing forms of identity and community made possible
by the Internet and globalization and fueled by culture change, conflict, and creative
intermixing.
One dilemma that the CFI may not sufficiently address is that identity is a co-
construction that emerges at the boundaries between different cultures, communi-
ties, and ways of being. Identity is always vis-à-vis another, so that how patients
describe themselves and, more deeply, who they understand themselves to be de-
pend on the context, including who is asking the questions, what setting they are in,
and what larger social circumstances are in play. These larger circumstances may in-
clude relationships involving both local and transnational networks and events oc-
curring both locally and in distant places that affect how individuals think and feel
about identity and the kind of responses they expect to get from others. For exam-
ple, when war is waged in one part of the world, people from groups involved in
the conflict will experience intense pressures to affirm or disavow potential aspects
of their identities, with consequences for how they narrate their identity. For the cli-
nician to gain a more rounded picture of the range of identities relevant to patients’
illness experience, it is useful to think of identity as socially situated and to ask
about facets of identity that may be salient or in the foreground in specific contexts
of home, school, workplace, or community, as well as in transnational networks
maintained by travel and telecommunications (Doucerain et al. 2013).
Similar issues apply to every aspect of the CFI. The ways that people think about
illness, adopt coping strategies, and seek help also depend on social contexts. The in-
teraction of local and global processes is evident in illness experience and in psycho-
social aspects of illness and healing. Patients may be influenced not only by their own
cultural background but also by diverse perspectives within their families, among co-
workers, and in local communities and global networks. There is a global circulation
of information about mental health problems and treatments, both explicitly and in-
directly through stories about media figures and others, that can exert strong effects
on how individuals understand and approach their own difficulties. Some of these in-
fluences may occur outside of patients’ awareness because they become part of taken-
for-granted background knowledge. The CFI–Informant Version (and corresponding
components of the CFI supplementary modules) can help clinicians understand some
of this tacit social and cultural background. Community members, religious leaders,
and others can provide more general information needed to make sense of the pa-
tient’s predicament.
All of this diversity is part of the dynamic mix of culture. Appreciating these dy-
namics should encourage the clinician to think of culture not simply as traits shared
by individuals with similar backgrounds but as complex histories and current con-
texts. Culture, then, is located not merely in the individual but also in the social
world, and clinical assessment of culture is about this context as much as it is about
the individual. Hence, the clinician needs to consider sources of information about
current cultural frameworks beyond what the patient can explicitly describe.
Another related dilemma in the process of cultural assessment is that many as-
pects of culture reside in everyday practices, ways of looking at the world, and social
arrangements that are taken for granted by participants. Hence, these aspects tend to
Conclusion 271
be tacit or invisible and hard for the patient to articulate. It is not sufficient, therefore,
for the clinician simply to ask the patient about his or her social context and experi-
ence. The clinician must know where to look for clinically relevant cultural issues:
what aspects of life to inquire about, what language to use to elicit the patient’s own
understandings, and who else to speak with to gain some appreciation of contextual
issues that are not part of the patient’s current self-awareness even though they may
be major social determinants of health and influences on his or her illness.
Implementing the CFI: Structure and Process

The CFI can contribute to a person-centered approach to psychiatry by emphasizing
the patient’s perspective. The core CFI begins with a question about the patient’s rea-
son for coming for help and makes that reason the center of the initial discussion be-
fore moving out to consider the wider context of illness. In effect, the CFI aims to elicit
information that can complement the usual diagnostic formulation by assaying the
social and cultural dimensions of illness experience, identity, coping, help seeking,
and expectations for care. Ideally, the CFI would contribute to a comprehensive bio-
psychosocial review of systems (Campbell and Rohrbaugh 2006; Harkness et al.
2014). Just as physicians learn to conduct a review of functional systems, organized
in terms of underlying physiology, the CFI can be seen as a tool for conducting a psy-
chosocial review of systems, which necessarily includes not only information on so-
cial determinants of health and illness in development and current life contexts but
also patients’ own narratives of identity, illness experience, values, and relationships,
as well as the views of others in their social networks. The goal is to identify predis-
posing, precipitating, perpetuating, and protective factors, which may be at multiple
systemic levels: individual, couple, family, community, health care system, and larger
social networks (Weerasekera 1996).
The quality of information obtained by the CFI depends crucially on the clinician-
patient relationship. Although use of the CFI can ultimately contribute to improving
the relationship, the success of this process will reflect the extent to which the clinician
is able to convey qualities of warmth, respect, competence, and concern. Beginning
the interview with attention to the patient’s presented complaints confirms the clini-
cian’s focus on the patient’s concerns and on a line of inquiry that will lead to helpful
interventions or recommendations. The various shifts of topic that occur in the CFI
should occur in a natural way as the conversation unfolds but may require explicit
discussion and justification with patients who do not see the connection between
their presented complaints and the clinician’s inquiries. This may be particularly the
case when asking about cultural identity. For some patients, this line of questioning
is welcome attention to a key aspect of their concerns, whereas for others it may be
experienced as intrusive and threatening. Explaining the potential links between
identity and health problems and solutions will suffice for most patients, but in some
cases questions need to be deferred until further trust is built and the relationship
strengthened.
Implementing the CFI requires attention to issues of cultural safety (Kirmayer
2012). People from groups that have experienced colonization, racism, discrimina-
tion, and marginalization by dominant groups in the society may approach institu-
tions with caution or mistrust. Clinicians whom patients view as part of oppressive
groups or institutions may have difficulty achieving the trust needed for effective as-
sessment. Cultural safety requires thinking through some of these potential barriers
to engagement in advance and taking steps to ensure that the institution, clinical set-
ting, and conduct of health professionals convey respect for the history of structural
violence and exclusion (Kirmayer 2011; Kirmayer et al. 2013).
The CFI can be an essential tool in culturally competent care. Skillful use of the
CFI, however, requires broader cultural competence. Cultural competence begins
with self-understanding. It goes on to include generic knowledge about how to ex-
plore culture (working with interpreters and culture brokers and elaborating ques-
tions to pursue particular lines of inquiry) and specific knowledge about the patient’s
culture, language, ethnicity, and religion. Competence at the level of the clinician
must be complemented by competence at the level of the health care system, organi-
zation, or institution (see subchapter “Administrative Perspectives on the Implemen-
tation and Use of the Cultural Formulation Interview”).
Working with interpreters, involving family and community, and taking the time
needed to build trust and understand patients from different backgrounds all require
additional time that must be factored into institutional practices and procedures, in-
cluding resource allocation and reimbursement structures. The additional time that
may be needed can pose a challenge in situations in which resources are limited or
there are pressures for standardization of care, but it is important to recognize that
providing equitable care requires addressing linguistic and cultural barriers to care
by mobilizing appropriate resources.
From Interview to Formulation

The development of an interview to guide data collection is a first step in facilitating
cultural formulation. The OCF provides a simple schema for recording the informa-
tion under broad domains, but the DSM-5 process stopped short of developing a
more structured template that could organize the data in ways that would facilitate
access and help make links to specific clinical issues. The challenge that remains is
providing guidance on how to integrate the data into a clinically useful formulation.
Just as psychodynamic, behavioral, or systemic formulations depend on relevant
knowledge and theoretical models (e.g., Chisolm and Lyketsos 2012; Hofmann 2014;
Johnstone and Dallos 2013; Reilly and Newton 2011), so too does cultural formulation
ultimately depend on evidence-based models and theory drawn from social science
and cultural psychiatry (Hays 2008; Kirmayer et al. 2014a). Given the breadth of is-
sues, there is no simple way to cover all of the potentially relevant links, which will
differ by cultural context, type of disorder, and personal history. In this section, I draw
from clinical experience in cultural psychiatry to outline the kinds of models and di-
mensions likely to be relevant and to suggest some potential organizing schemas.
Table 6–2 presents a list of common themes in cultural formulations conducted by the
Cultural Consultation Service of the Jewish General Hospital in Montreal (Kirmayer et
al. 2014a). To some extent, these themes reflect the particular patient population referred
Conclusion 273
TABLE 6–2. Common themes in cultural formulations

Family systems issues
Family and couple conflicts
Changes in configuration of extended family
Intergenerational issues
Family honor and obligations
Exposure to trauma and violence
Impact of war, torture, and organized violence
Domestic violence
Effects of violence on child development
Posttraumatic stress disorder, depression, and other sequelae
Migration issues
Stresses and loss during migration trajectory
Uncertainty of refugee or immigration status
Family separation and reunification
Homesickness and mourning for culture
Cultural identity, acculturation, and adjustment
Shifting/hybrid cultural identity
Adjusting to life in host country postmigration
Changing gender roles
Changing social roles and community relations
Cultural models of illness and healing
Modes of symptom expression and idioms of distress
Illness explanatory models and causal attributions
Cultural influences on social determinants of health
Treatment choice and expectations for care
Other social, economic, and structural issues
Stereotyping, prejudice, racism, and discrimination
Social isolation and marginalization
Unemployment and underemployment
Poverty and economic uncertainty
Source. Adapted from Kirmayer et al. 2014a, p. 38.
to this service (i.e., a high proportion of newcomers to Canada, with many refugees and
asylum seekers, as well as many migrants from South Asia, Africa, and the Middle East).
The themes also reflect the particular conceptual frameworks that consultants working
for the Cultural Consultation Service bring to bear to make sense of the cases. Clinicians
working with other populations and employing other conceptual frameworks will likely
highlight somewhat different themes. In the end, the validity and clinical relevance of the
theme must be judged by how much it resonates with patients’ own understandings and,
especially, how well it leads to effective clinical interventions.
Typically, a cultural formulation involves many themes that are intertwined. Some
of these are related to how patients understand their problems, and they are crucial for
effective clinical communication, engagement, and negotiation of treatment plans.
Other themes point toward specific mechanisms or processes that may give rise to par-
ticular symptoms or forms of psychopathology and that can be targeted with specific
interventions. Explaining the symptoms and course of psychopathology in terms of
underlying mechanisms is a goal of psychiatric science, and the hope is that this will
lead to more effective treatments. However, the assumption is often that the main
mechanisms of psychopathology will be found in disturbed neurophysiology. Cul-
tural psychiatry suggests that social factors can also be understood as causal explana-
tions that have their own psychophysiological, sociophysiological, and psychosocial
mechanisms. The study of these mechanisms can lead to new kinds of causal explana-
tions, which contribute to a case formulation in terms of pathological processes (and
sources of resilience and healing) that can guide clinical intervention.
This potential for cultural formulation including mechanisms is illustrated in
Table 6–3, which identifies some processes that can be used to think about the inter-
actions of culture with psychopathology and clinical presentations. This is necessarily
an open-ended list with no simple structure yet apparent. Both theoretical and empir-
ical work are needed to develop systematic frameworks to guide clinical thinking.
Integrating the information derived from the CFI into clinical case formulations
requires attention to events and experiences in the patient’s past (e.g., personal and
family history), the current context (e.g., stressors and supports), and the values and
expectations that guide future options (e.g., aspirations, norms, constraints). These
can be thought of at an individual level, but some of the dimensions of culture affect
a whole group, community, or population and exert their effects both directly on in-
dividuals and indirectly through effects on others or on social institutions and envi-
ronments. These influences often are not discrete events but instead occur over
extended periods of time, affecting developmental trajectories or the course of illness.
Hence, a temporal perspective is required.
The cultural formulation can be integrated into the standard medical case history,
with relevant aspects assigned to the history of present illness, personal and family
history, and mental status examination. However, these may not provide sufficient re-
minders to the clinician to consider processes related to specific dimensions of culture
and social context. The CFI and OCF provide broad categories, but the process of
translating this information into a case formulation suggests additional components
or dimensions. Table 6–4 suggests another way to organize cultural formulation in
terms of a grid that considers factors that influence illness at different stages in its
course or evolution: 1) the causes of illness; 2) the form of illness experience and
symptomatology; 3) coping and help seeking; 4) treatment response; 5) adaptation,
functional impairment, and recovery; and 6) the social responses to these outcomes,
which may include stigmatization and marginalization or support and integration.
Each of these stages in the evolution of illness can also be thought of in terms of a
nested hierarchy of system levels: subpersonal processes of cognition and emotion,
personal psychodynamics or self-systems, interpersonal, family, community (includ-
ing institutional settings such as work, school, or the health care system itself), nation
Conclusion 275
TABLE 6–3. Potential mechanisms in cultural formulation

Social and cultural contributors to etiology
Social determinants of health
Differential exposure to stressors or other causal agents
Cultural issues that give rise to specific types of conflict
Intrapsychic
Interpersonal
Between the family and the ethnic community (locally or transnationally)
Between the person, family, or community and the larger society or its institutions
Problems directly related to migration, citizenship status, and acculturation
Problems related to family systems dynamics influenced by cultural variations in the compo-
sition and structure of the family, gender- and age-related roles and norms, developmental
transitions, and cultural notions of honor
or society, transnational networks, and global systems. Each of these levels and stages
is embedded in larger temporal processes that include collective histories that may
antecede and frame patients’ individual experiences; developmental trajectories; au-
tobiographical narratives of the self that govern identity and life projects; current so-
cial contexts; and future aspirations. This third dimension of time can be included
within the cells of the two-dimensional grid or added as specific description of rele-
vant contexts and temporal trajectories (Table 6–5).
Evidence-Based Cultural Formulation

Cultural formulation should be evidence based, but developing the relevant evidence
requires psychiatric research that addresses the diversity of populations, settings, and
problems to identify specific aspects of culture and context that influence psychopa-
thology, treatment, and recovery (Whitley et al. 2011). The ways in which knowledge
of specific sociocultural processes can be integrated into cultural formulations can be
illustrated with a few examples from the research literature.
In terms of causal processes, culturally mediated developmental experiences may
increase vulnerability or resilience to specific types of mental health problems. Histo-
ries of colonization, ethnic conflict, slavery, and other events give rise to social struc-
tures of inequality and structural violence that powerfully affect individuals’ mental
health (Metzl and Hansen 2014). During development, individuals will have differ-
ential exposures to adverse life events and potential resources for resilience that will
influence their developmental trajectories. The ways in which individuals come to
frame their identities—which are partly a consequence of these collective histories
and developmental experiences but which, at some point, involve a measure of choice
and active self-fashioning—have implications for their positioning and subsequent
vulnerability to illness. Cultural contexts also may give rise to specific social determi-
nants of health, such as poverty and economic inequality, racism and discrimination,
and social marginalization (Braveman et al. 2011). For example, there is much evi-
276
TABLE 6–4. A grid for cultural formulation
Course of illness
Functioning,
Symptoms and Coping and Treatment adaptation,
Systemic level Causal factors signs of illness help seeking response and recovery Social response
Subpersonal
Personal

Interpersonal
Family
Community
Society
Transnational
Global systems
Conclusion 277
TABLE 6–5. Temporal Frames in Cultural Formulaton
Temporal frames Examples
Collective social history Colonization, slavery, collective violence

Developmental history Child-rearing practices
Personal history Identity, migration, trauma, acculturation
Current contexts Structural violence, racism, discrimination
Future Expectations and aspirations
dence for increased rates of psychosis among some populations that migrate to north-
ern Europe from southern countries or former colonies (Cantor-Graae 2007). This
increase does not seem to reflect elevated rates in countries of origin but is an effect
that occurs over time in the new country, and the risk for psychosis is, in some in-
stances, still greater for the second generation (Bourque et al. 2011). It is unclear pre-
cisely what social factors contribute to this increased risk, but exposure to structural
violence, racism, and discrimination may play an important role. Additionally, the
discrepancy between expectations and opportunities as a result of inequalities may
be an important causal factor in feelings of demoralization or “social defeat”
(Luhrmann 2007). Understanding patients’ migration history and current exposures
to discrimination (including subtle forms of microaggression and structural barriers
to educational and economic advancement) therefore may be an important part of as-
sessing risk and devising interventions that can reduce vulnerability and promote re-
covery and well-being (Sue et al. 2007). Attention to discrimination and structural
processes of disadvantage has implications for public health interventions and social
policy as well. There is evidence, for example, that neighborhood ethnic density may
play a buffering role for some ethnocultural groups, reducing the stressful effects of
being a discriminated-against minority (Bosqui et al. 2014). Considering the neigh-
borhoods where patients live may thus be an important part of clinical assessment to
identify both stressors and sources of resilience.
The experience and expression of mental health problems are shaped by symptom
and illness schemas and explanations (Gone and Kirmayer 2010). Illness schemas can
give rise to culture-specific symptoms and, when the attribution or interpretation re-
sults in emotional distress or stigmatization, may actually exacerbate symptoms and
result in distress and disability (Kirmayer and Sartorius 2009). Such vicious circles
mediated by culture-specific attributions have been well described for panic attacks
(Hinton and Good 2009).
Explanatory models can also influence the diagnostic process and the course of ill-
ness. For example, there is evidence that paranoid thinking among patients from some
ethnoracial minority groups may reflect consequences of endemic racism and discrimina-
tion (Whaley and Geller 2007). Experiences of racism and discrimination may contribute
to symptom presentation, making patients with primary affective disorders appear to
have psychotic symptoms. Knowledge of local cultural norms is needed to judge the level
of paranoid ideation that indicates psychopathology (Chapman et al. 2014). Systematic
evaluation of cultural norms and contexts of illness expression can improve the accuracy
of diagnoses of psychosis (Adeponle et al. 2012a, 2014).
Cultural factors influence the ways in which patients and their families cope with
illness and seek help. There is evidence that underutilization of mental health services
among many groups may reflect negative perceptions of health care institutions
based on collective histories, past experiences, or specific illness interpretations
(Snowden and Yamada 2005).
Adaptation to illness, treatment response, and recovery are all shaped by cultural
histories, contexts, and values. Evidence suggests that negative expressed emotion in
families can exacerbate psychotic illness and increase relapse rates. Culturally based
styles of emotional expression, as well as illness explanations, may mitigate negative
expressed emotion in families, with effects on the course of illness (Aguilera et al.
2010; Karno et al. 1987). Recognizing such factors can allow the clinician to tailor psy-
choeducational and systemic interventions to improve outcome.
Current discussions of recovery highlight the diverse ways in which people may
find meaning in their symptoms and suffering and the ways they may prioritize dif-
ferent domains of their life to judge whether or not interventions are helpful (Whitley
and Drake 2010). The meanings of suffering, and the values, goals, and aspirations
against which illness and recovery are assessed, vary with culture and social position
(Adeponle et al. 2012b).
The examples discussed in this section are only meant to illustrate how the infor-
mation collected through the CFI can be organized in clinically relevant formulations.
Knowledge of specific processes, based on experience and research, can guide both
the process of collecting information and the formulation to yield an expanded prob-
lem list, treatment plan, and strategies for interventions. The refinement of methods
of cultural formulation requires further research on social and cultural processes in
psychopathology (Alarcón et al. 2002). Research may lead to the recognition of new
kinds of mechanisms of psychopathology and recovery, and this, in turn, can inform
methods of clinical case formulation.
A Research Agenda for the CFI

There is a need for research on the CFI itself, to refine its components and to evaluate
its effective implementation and impact on clinical outcomes. Although the CFI is
based on a wealth of clinical experience in diverse settings, its contents and scope can
be enlarged by research on the social and cultural determinants of health that identi-
fies the kinds of social adversity and predicaments that give rise to or exacerbate spe-
cific types of mental health problems and the kinds of individual and collective
resources and coping strategies that promote recovery. At the same time, the CFI pro-
vides a way to assess clinically relevant dimensions of history and context that can be
integrated into research on other dimensions of mental health problems, such as help-
ing to identify particular contexts or modes of gene-environment interaction that con-
tribute to the epigenetic and behavioral processes that contribute to psychopathology.
There is also a need for research on the clinical process of cultural assessment
itself. In particular, researchers need to examine how the CFI actually works in var-
Conclusion 279
ious contexts, in terms of both process (looking at interviews with various process-
oriented methods, including conversation analysis) and outcomes (in terms of what
kind of information the CFI collects that makes a difference to recovery). Both qual-
itative and quantitative studies of the interview process and the subsequent integra-
tion of cultural knowledge in diagnostic assessment and treatment planning are
needed (e.g., Adeponle et al. 2014). Studies comparing the effects of reassessment of
patients using the CFI with standard assessment can clarify the kinds of clinically
relevant information a culturally oriented interview obtains (e.g., Bäärnhielm and
Scarpinati Rosso 2009; Scarpinati Rosso and Bäärnhielm 2012).
Efforts were made to make the CFI as concise as possible. In actual practice, the
length of the interview will depend on the patient’s responses and the domains of
clinical concern. However, this concision raises questions about how adequately a
brief interview such as the CFI can elicit crucial clinical information, There is no single
“gold standard” for cultural assessment against which the CFI can be compared, but
comparisons with lengthier, more comprehensive assessments would be useful to de-
termine whether there are certain types of information, patients, or contexts that re-
quire other interview strategies. Novel methods for eliciting cultural information can
be explored as complements or alternatives to the CFI; these include the use of maps,
time lines, and drawings (e.g., Saint Arnault and Shimabukuro 2012).
The structure of the CFI was designed to follow a typical sequence in clinical in-
terviewing: beginning with questions about the patient’s presented complaints and
concerns and their meaning and interpretation; then moving to broader questions
about psychosocial stresses and supports, issues of cultural identity, help seeking,
and expectations for care; and finally posing questions about the clinician-patient re-
lationship. This order may need to be modified in certain situations. For example,
sometimes addressing identity issues at the outset can promote clinical trust and en-
gagement, forestalling early breakdowns in communication. This consideration may
be particularly important in settings where the safety or legitimacy of the clinician or
the institutional setting has been called into question by patients’ past histories of ex-
posure to racism, discrimination, or other forms of structural violence.
Research on the interview process with the CFI would look at the microdynamics
of the clinical interaction with and without the inclusion of an interpreter or culture
broker. It could compare different interview formats, sequences, and contents to iden-
tify modifications that can improve the assessment process.
The use of the CFI can also make a difference to treatment teams and organiza-
tions. For example, discussing the results of culturally oriented interviews in multi-
disciplinary case conferences can influence the dynamics of the group by providing
an explicit place for the perspectives of disciplines devoted to social-contextual un-
derstanding of mental health problems (Dinh et al. 2012). Making optimal use of the
skills of diverse disciplines in cultural formulation may involve changes in the pro-
fessional roles, modes of interaction, and organizational structure. Research on the or-
ganizational and systemic models of culturally responsive care will be important to
guide effective implementation of the CFI.
Ultimately, research that shows how the CFI makes a difference to clinical out-
comes is needed. These clinical impacts of the CFI that may be assessed in research
studies include changes in diagnosis, recognition of other situational problems, in-

creased treatment adherence, and improvements in the clinician-patient relationship.
Each of these may have direct and indirect effects on clinical outcomes. Clearly, if a
major diagnosis changes as a result of cultural formulation, the patient is likely to re-
ceive a new, more appropriate treatment, with corresponding improvement in out-
come. Identifying additional problems, beyond diagnosis, that can be addressed
through psychosocial or other interventions should also have measurable impacts
that will interact with treatment for any psychiatric disorder. Improving clinical en-
gagement and adherence will ensure that treatments are successfully delivered. Im-
proving clinical communication should help patients better understand their
problems and make more appropriate and effective use of mental health services.
Studies of the effectiveness of the CFI, therefore, should consider these multiple levels
of outcome.
Promoting Use of the CFI Through

Training and Continuing Education
Clinical training aims to transmit the knowledge and skills needed to work in a wide
variety of settings to address the range of problems presented by diverse patient pop-
ulations. Learning to use the CFI should be a core clinical competency (Kirmayer et
al. 2012). The CFI provides a way to explore the cultural context and meanings of ill-
ness experience and help seeking and therefore facilitates acquiring generic cultural
competence.
In psychiatric training, practice in the use of the CFI (coupled with training in
working with interpreters and culture brokers) can provide residents with basic skills
to work in a wide variety of settings. Indeed, it is important to emphasize that the CFI
can be used with any patient, and having trainees use it with patients from their own
cultural background provides a good opportunity to help them become aware of their
own cultural assumptions and the contexts in which they work, as well as the wide
variations in experience within even familiar groups (Kirmayer et al. 2014b). This
kind of pedagogical experience can help reduce the tendency to stereotype others and
to encourage a more dynamic view of the interplay of individual agency with cultural
resources and constraints. Intercultural work also requires a high tolerance for ambi-
guity and uncertainty, and training programs must provide safe spaces and role mod-
els for this work (Guzder and Rousseau 2013).
Accreditation standards for mental health training programs need to move be-
yond general criteria for cultural competence to include specific mention of the use of
the CFI and related skills. New generations of clinicians will likely encounter the CFI
as they become familiar with DSM-5, but particular efforts need to be made to reach
earlier generations of clinicians currently in practice. Quality assurance and recertifi-
cation standards that include cultural competence can make explicit note of skill in
using the CFI as a criterion. To implement these standards, there is a need to develop
further training materials, such as the videos that accompany this volume, as well as
self-assessment tools that can be presented through continuing education workshops
Conclusion 281
and online self-guided training and assessment.

Although developed as an interview protocol to explore cultural issues, the CFI
operationalizes some key aspects of a patient-centered approach to health care (Mez-
zich et al. 2010) and therefore has implications beyond the challenge of addressing
cultural diversity. The CFI also can be a useful tool in the training context, with rele-
vance beyond psychiatry. Rooted as it is in the perspectives of medical anthropology,
the CFI is useful for teaching patient-centered medicine at all levels of training (see
Chapter 5, “Cultural Competence in Psychiatric Education Using the Cultural For-
mulation Interview”). Indeed, use of the CFI and similar interviews in primary care
and internal medicine settings can help students and faculty grasp the elements of a
person-centered approach to clinical assessment (Groleau et al. 2013). At the same
time, the issues identified through the CFI provide an opportunity for trainees to
learn more about specific social and cultural topics relevant to the care of particular
kinds of patients and populations.
Conclusion
Culture is increasingly recognized as central to diagnostic assessment both to im-
prove diagnostic accuracy and to deepen understanding of patients’ problems in con-
text. DSM-5 directly addresses several of the limitations of previous DSM editions.
Concepts of culture have been refined based on current social science research. The
OCF has been expanded to include a greater range of relevant cultural issues. Most
significantly, DSM-5 includes the core CFI, the CFI–Informant Version, and the sup-
plementary modules, which can guide clinical assessment of cultural dimensions. To
become part of the tool kit of mental health practitioners, the CFI needs to be included
in clinical training programs and incorporated into mental health services. Its in-
creased use can contribute to improving mental health care for members of minority
groups, migrants, and other communities likely to have distinctive illness experi-
ences due to cultural differences. However, culture is important for everyone, and in-
tegrating the CFI into standard care can foster more patient-centered approaches that
give due attention to each individual’s unique history, lifeworld, and values that are
rooted in particular social and cultural contexts. This attention to history and context
is a matter not only of recognizing culture as a key dimension of identity but also as
a path to more personalized care.
Culture is a moving target, undergoing constant transformation, and the ways in
which identity is understood and clinically relevant aspects of social context are rec-
ognized today will likely change over time. Changing meanings of culture and social
contexts will also give rise to new mechanisms of psychopathology or adaptation and
corresponding new areas to explore in the CFI. For example, Internet use has created
new forms of behavioral addiction or problematic use of media, and these will have
neurobiological, psychological, social, and economic consequences for individuals—
all of which may be relevant to cultural formulation that aims to clarify mechanisms,
guide treatment planning, and predict outcome (Kirmayer et al. 2013).
Clearly, there is an ethical mandate to address culture when it constitutes a crucial
element in delivering safe and effective care. Problems in communication due to cul-
tural and linguistic differences can result in misunderstandings, inaccurate diagnos-

tic assessments, inappropriate treatments, poor clinical engagement and adherence,
and, ultimately, negative outcomes. Concerns about the time and effort involved in
cultural formulation must be weighed against these potentially serious consequences
of ignoring difference. Of course, there are limits to how well we as clinicians can
know patients’ experience, because of divergent life trajectories and situations. The
ethical implications of the epistemic challenges and constraints of cultural assessment
also point to a deeper problem of empathy at the limits of understanding (Kirmayer
2008). Recognizing the limits of understanding calls for cultural humility (Tervalon
and Murray-García 1998). Indeed, the philosopher Emmanuel Levinas (Levinas 2003)
argued that this situation is basic to the human condition—that is, each person is at
once familiar and like us but also fundamentally different, strange and “other,” and
the recognition of otherness or alterity calls us to an ethical stance of respect, concern,
and protectiveness toward the vulnerable other. This recognition that our under-
standing of the other is always limited and incomplete enjoins us to remain open to
the other and to maintain a stance of collaborative inquiry in the clinical relationship.
This ethics of inquiry grounded in respect and responsibility informs the guidelines
for the CFI and can help the clinician tailor and adapt the interview process to meet
the needs of each patient.
KEY CLINICAL POINTS

• Culture and context are relevant to every aspect of illness experience and health
care for patients from every background.
• The Cultural Formulation Interview (CFI) addresses a key component of person-
centered care by focusing attention on patients’ experience as well as the social
contexts of their illness.
• Further work is needed to systematize the process of translating the information
collected through the CFI into a case formulation.
• Changes in organizational structure, training, and accreditation to ensure cultural
safety and competence are needed to promote the use of the CFI.
• The meanings and mental health implications of cultural identity, knowledge, and
practices need to be revisited as our local social worlds and global networks con-
tinue to evolve.
Questions
1. What are some of the differences between the DSM framing of disorders and a
cultural perspective?
2. What trade-offs between practical and theoretical considerations were in-

volved in the development of the CFI?
Conclusion 283
3. What are useful frameworks for organizing and recording the results of the CFI?
4. What kinds of research are needed for further development of the CFI?
5. How can the use of cultural formulation be promoted and institutionalized in

psychiatric practice?
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Appendixes A–C
Cultural Formulation Interview–Core Version
Cultural Formulation Interview–Informant Version
Supplementary Modules
The APA is offering the Cultural Formulation Interview (including

the Informant Version) and the Supplementary Modules to the core Cul-
tural Formulation Interview for further research and clinical evaluation.
They should be used in research and clinical settings as potentially useful
tools to enhance clinical understanding and decision-making and not as
the sole basis for making a clinical diagnosis. Additional information can
be found in DSM-5 in the Section III chapter “Cultural Formulation.” The
APA requests that clinicians and researchers provide further data on the
usefulness of these cultural formulation interviews at http://
www.dsm5.org/Pages/Feedback-Form.aspx. To request permission for
any other use beyond what is stipulated above, contact: http://
www.appi.org/CustomerService/Pages/Permissions.aspx
Appendix A
Cultural Formulation Interview (CFI)–Core Version
The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may
use to obtain information during a mental health assessment about the impact of cul-
ture on key aspects of an individual’s clinical presentation and care. In the CFI, culture
refers to
• The values, orientations, knowledge, and practices that individuals derive from
membership in diverse social groups (e.g., ethnic groups, faith communities, oc-
cupational groups, veterans groups).
• Aspects of an individual’s background, developmental experiences, and current
social contexts that may affect his or her perspective, such as geographical origin,
migration, language, religion, sexual orientation, or race/ethnicity.
• The influence of family, friends, and other community members (the individual’s
social network) on the individual’s illness experience.
The CFI is a brief semistructured interview for systematically assessing cultural

factors in the clinical encounter that may be used with any individual. The CFI fo-
cuses on the individual’s experience and the social contexts of the clinical problem.
The CFI follows a person-centered approach to cultural assessment by eliciting in-
formation from the individual about his or her own views and those of others in his
or her social network. This approach is designed to avoid stereotyping, in that each
individual’s cultural knowledge affects how he or she interprets illness experience
and guides how he or she seeks help. Because the CFI concerns the individual’s per-
sonal views, there are no right or wrong answers to these questions. The interview
follows and is available online at www.psychiatry.org/practice/dsm/dsm5/online-
assessment-measures.
The CFI is formatted as two text columns. The left-hand column contains the in-
structions for administering the CFI and describes the goals for each interview do-
main. The questions in the right-hand column illustrate how to explore these
domains, but they are not meant to be exhaustive. Follow-up questions may be
needed to clarify individuals’ answers. Questions may be rephrased as needed. The
CFI is intended as a guide to cultural assessment and should be used flexibly to main-
tain a natural flow of the interview and rapport with the individual.
289
The CFI is best used in conjunction with demographic information obtained prior
to the interview in order to tailor the CFI questions to address the individual’s back-
ground and current situation. Specific demographic domains to be explored with the
CFI will vary across individuals and settings. A comprehensive assessment may in-
clude place of birth, age, gender, racial/ethnic origin, marital status, family composi-
tion, education, language fluencies, sexual orientation, religious or spiritual
affiliation, occupation, employment, income, and migration history.
The CFI can be used in the initial assessment of individuals in all clinical settings,
regardless of the cultural background of the individual or of the clinician. Individuals
and clinicians who appear to share the same cultural background may nevertheless
differ in ways that are relevant to care. The CFI may be used in its entirety, or compo-
nents may be incorporated into a clinical evaluation as needed. The CFI may be espe-
cially helpful when there is
• Difficulty in diagnostic assessment owing to significant differences in the cultural,

religious, or socioeconomic backgrounds of clinician and the individual.
• Uncertainty about the fit between culturally distinctive symptoms and diagnostic
criteria.
• Difficulty in judging illness severity or impairment.
• Disagreement between the individual and clinician on the course of care.
• Limited engagement in and adherence to treatment by the individual.
The CFI emphasizes four domains of assessment: Cultural Definition of the Prob-
lem (questions 1–3); Cultural Perceptions of Cause, Context, and Support (questions
4–10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11–13);
and Cultural Factors Affecting Current Help Seeking (questions 14–16). Both the per-
son-centered process of conducting the CFI and the information it elicits are intended
to enhance the cultural validity of diagnostic assessment, facilitate treatment planning,
and promote the individual’s engagement and satisfaction. To achieve these goals, the
information obtained from the CFI should be integrated with all other available clini-
cal material into a comprehensive clinical and contextual evaluation. An Informant
version of the CFI can be used to collect collateral information on the CFI domains
from family members or caregivers.
Supplementary modules have been developed that expand on each domain of the
CFI and guide clinicians who wish to explore these domains in greater depth. Supple-
mentary modules have also been developed for specific populations, such as children
and adolescents, elderly individuals, and immigrants and refugees. These supple-
mentary modules are referenced in the CFI under the pertinent subheadings and are
available online at www.psychiatry.org/practice/dsm/dsm5/online-assessment-
measures.
DSM-5 Cultural Formulation Interview–Core Version 291
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
INSTRUCTIONS TO THE INTERVIEWER ARE

GUIDE TO INTERVIEWER ITALICIZED.
The following questions aim to clarify key aspects of INTRODUCTION FOR THE INDIVIDUAL:
the presenting clinical problem from the point of I would like to understand the problems that
view of the individual and other members of the bring you here so that I can help you more
individual’s social network (i.e., family, friends, or effectively. I want to know about your experi-
others involved in current problem). This includes ence and ideas. I will ask some questions
the problem’s meaning, potential sources of help, about what is going on and how you are deal-
and expectations for services. ing with it. Please remember there are no
right or wrong answers.
CULTURAL DEFINITION OF THE PROBLEM
(Explanatory Model, Level of Functioning)
Elicit the individual’s view of core problems and key 1. What brings you here today?
concerns. IF INDIVIDUAL GIVES FEW DETAILS OR
Focus on the individual’s own way of understand- ONLY MENTIONS SYMPTOMS OR A
ing the problem. MEDICAL DIAGNOSIS, PROBE:
Use the term, expression, or brief description elicited People often understand their problems in
in question 1 to identify the problem in subsequent their own way, which may be similar to or
questions (e.g., “your conflict with your son”). different from how doctors describe the
problem. How would you describe your
problem?
Ask how individual frames the problem for members 2. Sometimes people have different ways of
of the social network. describing their problem to their family,
friends, or others in their community. How
would you describe your problem to them?
Focus on the aspects of the problem that matter most 3. What troubles you most about your prob-
to the individual. lem?
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
CAUSES
(Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition 4. Why do you think this is happening to
for the individual, which may be relevant for clin- you? What do you think are the causes of
ical care. your [PROBLEM]?
Note that individuals may identify multiple causes, PROMPT FURTHER IF REQUIRED:
depending on the facet of the problem they are con- Some people may explain their problem as
sidering. the result of bad things that happen in their
life, problems with others, a physical ill-
ness, a spiritual reason, or many other
causes.
Focus on the views of members of the individual’s 5. What do others in your family, your
social network. These may be diverse and vary friends, or others in your community think
from the individual’s. is causing your [PROBLEM]?
Copyright  2013 American Psychiatric Association. All Rights Reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

STRESSORS AND SUPPORTS

(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and
Refugees, Cultural Identity, Older Adults, Coping and Help Seeking)
Elicit information on the individual’s life context, 6. Are there any kinds of support that make
focusing on resources, social supports, and your [PROBLEM] better, such as support
resilience. May also probe other supports (e.g., from family, friends, or others?
from co-workers, from participation in religion
or spirituality).
Focus on stressful aspects of the individual’s envi- 7. Are there any kinds of stresses that make
ronment. Can also probe, e.g., relationship prob- your [PROBLEM] worse, such as difficul-
lems, difficulties at work or school, or ties with money, or family problems?
discrimination.
ROLE OF CULTURAL IDENTITY
(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees,
Older Adults, Children and Adolescents)
Sometimes, aspects of people’s background
or identity can make their [PROBLEM] bet-
ter or worse. By background or identity, I
mean, for example, the communities you
belong to, the languages you speak, where
you or your family are from, your race or
ethnic background, your gender or sexual
orientation, or your faith or religion.
Ask the individual to reflect on the most salient ele- 8. For you, what are the most important
ments of his or her cultural identity. Use this aspects of your background or identity?
information to tailor questions 9–10 as needed.
Elicit aspects of identity that make the problem bet- 9. Are there any aspects of your background
ter or worse. or identity that make a difference to your
Probe as needed (e.g., clinical worsening as a result [PROBLEM]?
of discrimination due to migration status, race/
ethnicity, or sexual orientation).
Probe as needed (e.g., migration-related problems; 10. Are there any aspects of your background
conflict across generations or due to gender roles). or identity that are causing other concerns
or difficulties for you?
CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING
SELF-COPING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers,
Psychosocial Stressors)
Clarify self-coping for the problem. 11. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What have you done on your own to cope
with your [PROBLEM]?

DSM-5 Cultural Formulation Interview–Core Version 293

PAST HELP SEEKING

(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial
Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)
Elicit various sources of help (e.g., medical care, 12. Often, people look for help from many differ-
mental health treatment, support groups, work- ent sources, including different kinds of doc-
based counseling, folk healing, religious or spiri- tors, helpers, or healers. In the past, what
tual counseling, other forms of traditional or kinds of treatment, help, advice, or healing
alternative healing). have you sought for your [PROBLEM]?
Probe as needed (e.g., “What other sources of help PROBE IF DOES NOT DESCRIBE USE-
have you used?”). FULNESS OF HELP RECEIVED:
Clarify the individual’s experience and regard for What types of help or treatment were most
previous help. useful? Not useful?
BARRIERS
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immi-
grants and Refugees, Social Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking, 13. Has anything prevented you from getting
access to care, and problems engaging in previous the help you need?
treatment. PROBE AS NEEDED:
Probe details as needed (e.g., “What got in the For example, money, work or family com-
way?”). mitments, stigma or discrimination, or lack
of services that understand your language
or background?
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
PREFERENCES
(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual’s current perceived needs and Now let’s talk some more about the help
expectations of help, broadly defined. you need.
Probe if individual lists only one source of help (e.g., 14. What kinds of help do you think would be
“What other kinds of help would be useful to you most useful to you at this time for your
at this time?”). [PROBLEM]?
Focus on the views of the social network regarding 15. Are there other kinds of help that your fam-
help seeking. ily, friends, or other people have suggested
would be helpful for you now?
CLINICIAN-PATIENT RELATIONSHIP
(Clinician-Patient Relationship, Older Adults)
Elicit possible concerns about the clinic or the clini- Sometimes doctors and patients misunder-
cian-patient relationship, including perceived rac- stand each other because they come from
ism, language barriers, or cultural differences that different backgrounds or have different
may undermine goodwill, communication, or care expectations.
delivery. 16. Have you been concerned about this and is
Probe details as needed (e.g., “In what way?”). there anything that we can do to provide
Address possible barriers to care or concerns about you with the care you need?
the clinic and the clinician-patient relationship
raised previously.

Appendix B
Cultural Formulation Interview (CFI)–Informant Version
The CFI–Informant Version collects collateral information from an informant who is
knowledgeable about the clinical problems and life circumstances of the identified in-
dividual. This version can be used to supplement information obtained from the core
CFI or can be used instead of the core CFI when the individual is unable to provide
information—as might occur, for example, with children or adolescents, floridly psy-
chotic individuals, or persons with cognitive impairment.

The following questions aim to clarify key aspects of INTRODUCTION FOR THE INFORMANT:
the presenting clinical problem from the infor- I would like to understand the problems that
mant’s point of view. This includes the problem’s bring your family member/friend here so
meaning, potential sources of help, and expecta- that I can help you and him/her more effec-
tions for services. tively. I want to know about your experience
and ideas. I will ask some questions about
what is going on and how you and your fam-
ily member/friend are dealing with it. There
are no right or wrong answers.
RELATIONSHIP WITH THE PATIENT
Clarify the informant’s relationship with the indi- 1. How would you describe your relationship
vidual and/or the individual’s family. to [INDIVIDUAL OR TO FAMILY]?
PROBE IF NOT CLEAR:
How often do you see [INDIVIDUAL]?
Elicit the informant’s view of core problems and key 2. What brings your family member/friend
concerns. here today?
Focus on the informant’s way of understanding the IF INFORMANT GIVES FEW DETAILS OR
individual’s problem. ONLY MENTIONS SYMPTOMS OR A
Use the term, expression, or brief description elicited MEDICAL DIAGNOSIS, PROBE:
in question 1 to identify the problem in subsequent People often understand problems in their
questions (e.g., “her conflict with her son”). own way, which may be similar or different
from how doctors describe the problem.
How would you describe [INDIVIDUAL’S]
problem?
Ask how informant frames the problem for members 3. Sometimes people have different ways of
of the social network. describing the problem to family, friends, or
others in their community. How would you
describe [INDIVIDUAL’S] problem to them?
Focus on the aspects of the problem that matter most 4. What troubles you most about [INDIVID-
to the informant. UAL’S] problem?

295

CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT

CAUSES
This question indicates the meaning of the condition 5. Why do you think this is happening to
for the informant, which may be relevant for clini- [INDIVIDUAL]? What do you think are the
cal care. causes of his/her [PROBLEM]?
Note that informants may identify multiple causes PROMPT FURTHER IF REQUIRED:
depending on the facet of the problem they are con- Some people may explain the problem as the
sidering. result of bad things that happen in their life,
problems with others, a physical illness, a
spiritual reason, or many other causes.
Focus on the views of members of the individual’s 6. What do others in [INDIVIDUAL’S] family,
social network. These may be diverse and vary his/her friends, or others in the community
from the informant’s. think is causing [INDIVIDUAL’S] [PROB-
LEM]?
STRESSORS AND SUPPORTS
Elicit information on the individual’s life context, 7. Are there any kinds of supports that make
focusing on resources, social supports, and resil- his/her [PROBLEM] better, such as from
ience. May also probe other supports (e.g., from family, friends, or others?
co-workers, from participation in religion or spiri-
tuality).
Focus on stressful aspects of the individual’s envi- 8. Are there any kinds of stresses that make
ronment. Can also probe, e.g., relationship prob- his/her [PROBLEM] worse, such as diffi-
lems, difficulties at work or school, or culties with money, or family problems?
discrimination.
ROLE OF CULTURAL IDENTITY
Sometimes, aspects of people’s background
or identity can make the [PROBLEM] better
or worse. By background or identity, I
mean, for example, the communities you
belong to, the languages you speak, where
you or your family are from, your race or
ethnic background, your gender or sexual
orientation, and your faith or religion.
Ask the informant to reflect on the most salient ele- 9. For you, what are the most important
ments of the individual’s cultural identity. Use this aspects of [INDIVIDUAL’S] background or
information to tailor questions 10–11 as needed. identity?
Elicit aspects of identity that make the problem bet- 10. Are there any aspects of [INDIVIDUAL’S]
ter or worse. background or identity that make a differ-
Probe as needed (e.g., clinical worsening as a result ence to his/her [PROBLEM]?
of discrimination due to migration status, race/
ethnicity, or sexual orientation).
Probe as needed (e.g., migration-related problems; 11. Are there any aspects of [INDIVIDUAL’S]
conflict across generations or due to gender roles). background or identity that are causing
other concerns or difficulties for him/her?

Cultural Formulation Interview–Informant Version 297

CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING

SELF-COPING
Clarify individual’s self-coping for the problem. 12. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What has [INDIVIDUAL] done on his/her
own to cope with his/her [PROBLEM]?
PAST HELP SEEKING
Elicit various sources of help (e.g., medical care, 13. Often, people also look for help from many
mental health treatment, support groups, work- different sources, including different kinds
based counseling, folk healing, religious or spiri- of doctors, helpers, or healers. In the past,
tual counseling, other alternative healing). what kinds of treatment, help, advice, or
Probe as needed (e.g., “What other sources of help healing has [INDIVIDUAL] sought for his/
has he/she used?”). her [PROBLEM]?
Clarify the individual’s experience and regard for PROBE IF DOES NOT DESCRIBE USE-
previous help. FULNESS OF HELP RECEIVED:
What types of help or treatment were most
useful? Not useful?
BARRIERS
Clarify the role of social barriers to help-seeking, access 14. Has anything prevented [INDIVIDUAL]
to care, and problems engaging in previous treatment. from getting the help he/she needs?
Probe details as needed (e.g., “What got in the PROBE AS NEEDED:
way?”). For example, money, work or family com-
mitments, stigma or discrimination, or lack
of services that understand his/her lan-
guage or background?
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
PREFERENCES
Clarify individual’s current perceived needs and Now let’s talk about the help [INDIVID-
expectations of help, broadly defined, from the UAL] needs.
point of view of the informant. 15. What kinds of help would be most useful to
Probe if informant lists only one source of help (e.g., him/her at this time for his/her [PROB-
“What other kinds of help would be useful to LEM]?
[INDIVIDUAL] at this time?”).
Focus on the views of the social network regarding 16. Are there other kinds of help that [INDIVID-
help seeking. UAL’S] family, friends, or other people have
suggested would be helpful for him/her now?
CLINICIAN-PATIENT RELATIONSHIP
Elicit possible concerns about the clinic or the clinician- Sometimes doctors and patients misunder-
patient relationship, including perceived racism, lan- stand each other because they come from
guage barriers, or cultural differences that may under- different backgrounds or have different
mine goodwill, communication, or care delivery. expectations.
Probe details as needed (e.g., “In what way?”). 17. Have you been concerned about this, and is
Address possible barriers to care or concerns about there anything that we can do to provide
the clinic and the clinician-patient relationship [INDIVIDUAL] with the care he/she
raised previously. needs?

Appendix C
Supplementary Modules to the Core Cultural
Formulation Interview (CFI)
Guidelines for Implementing the CFI Supplementary Modules
These modules supplement the core Cultural Formulation Interview and can help clinicians conduct a
more comprehensive cultural assessment. The first eight supplementary modules explore the domains of the
core CFI in greater depth. The next three modules focus on populations with specific needs, such as children
and adolescents, older adults, and immigrants and refugees. The last module explores the experiences and
views of individuals who perform caregiving functions, in order to clarify the nature and cultural context of
caregiving and how they affect social support in the immediate environment of the individual receiving care. In
addition to these supplementary modules, an Informant version of the core CFI collects collateral information on
the CFI domains from family members or caregivers.
Clinicians may use these supplementary modules in two ways:
x As adjuncts to the core CFI for additional information about various aspects of illness affecting
diverse populations. The core CFI refers to pertinent modules under each subheading to
facilitate such use of the modules.
x As tools for in-depth cultural assessment independent of the core CFI. Clinicians may
administer one, several, or all modules depending on what areas of an individual’s problems
they would like to elaborate.
Clinicians should note that a few questions in the modules duplicate questions in the core CFI (indicated
by an asterisk [*]) or in other modules. This makes it possible to administer each module independently.
Clinicians who use the modules as an adjunct to the core CFI or who administer the modules independently may
skip redundant questions.
As with the core CFI, follow-up questions may be needed to clarify the individual’s answers. Questions
may be rephrased as needed. The modules are intended as a guide to cultural assessment and should be used
flexibly to maintain a natural flow of the interview and rapport with the individual. In situations where the
individual cannot answer these questions (e.g., due to cognitive impairment or severe psychosis) these
questions can be administered to the identified caregiver. The caregiver’s own perspective can also be
ascertained using the module for caregivers.
In every module, instructions to the interviewer are in italics. The modules may be administered during
the initial clinical evaluation, at a later point in care, or several times over the course of treatment. Multiple
administrations may reveal additional information as rapport develops, especially when assessing the patient-
clinician relationship.
Please refer to DSM-5 Section III, chapter “Cultural Formulation,” sectionV “Outline for Cultural
Formulation” DQG&XOWXUDO)RUPXODWLRQ,QWHUYLHZ &), for additional suggestions regarding this type of interview.

299
1. Explanatory Model
Related Core CFI Questions: 1, 2, 3, 4, 5 Some of the core CFI questionV are repeated below and are marked with
an asterisk (*). The CFI question that is repeated is indicated in brackets.
GUIDE TO INTERVIEWER: This module aims to clarify the individual’s understanding of the problem based on his or
her ideas about cause and mechanism (explanatory models) and past experiences of, or knowing someone with, a
similar problem (illness prototypes). The individual may identify the problem as a symptom, a specific term or
expression (e.g., “nerves,” “being on edge”), a situation (e.g., loss of a job), or a relationship (e.g., conflict with others).
In the examples below, the individual’s own words should be used to replace “[PROBLEM]”. If there are multiple
problems, each relevant problem can be explored. The following questions may be used to elicit the individual’s
understanding and experience of that problem or predicament.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to understand the problems that bring
you here so that I can help you more effectively. I will be asking you some questions to learn more about your own
ideas about the causes of your problems and the way they affect your daily life.
General understanding of the problem

1. *Can you tell me more about how you understand your [PROBLEM]? [RELATED TO CFI Q#1-2.]
2. What did you know about your [PROBLEM] before it affected you?
Illness prototypes
3. Had you ever had anything like your [PROBLEM] before? Please tell me about that.
4. Do you know anyone else, or heard of anyone else, with this [PROBLEM]? If so, please describe that person’s
[PROBLEM] and how it affected that person. Do you think this will happen to you too?
5. Have you seen on television, heard on the radio, read in a magazine, or found on the internet anything about your
[PROBLEM]? Please tell me about it.
Causal explanations
6. *Can you tell me what you think caused your [PROBLEM]? (PROBE AS NEEDED: Is there more than one cause
that may explain it?] [RELATED TO CFI Q#4.)
7. Have your ideas about the cause of the [PROBLEM] changed? How? What changed your ideas about the
cause?
8. *What do people in your family, friends, or others in your community think caused the [PROBLEM]? (PROBE AS
NEEDED: Are their ideas about it different from yours? How so?) [RELATED TO CFI Q#5.]
9. How do you think your [PROBLEM] affects your body? Your mind? Your spiritual wellbeing?
Course of illness
10. What usually happens to people who have this [PROBLEM]? In your own case, what do you think is likely to
happen?
11. Do you consider your [PROBLEM] to be serious? Why? What is the worst that could happen?
12. How concerned are other people in your family, friends or community about your having this [PROBLEM]?
Please tell me about that.
Help seeking and treatment expectations

13. What do you think is the best way to deal with this kind of problem?
14. What do your family, friends, or others in your community think is the best way of dealing with this kind of
problem?

Supplementary Modules to the Core Cultural Formulation Interview 301
2. Level of Functioning
Related Core CFI Question: 3
GUIDE TO INTERVIEWER: The following questions aim to clarify the individual’s level of functioning in relation to his
or her own priorities and those of the cultural reference group. The interview begins with a general question about
everyday activities that are important for the individual. Questions follow about domains important for positive health
(social relations, work/school, economic viability, and resilience). Questions should be kept relatively broad and open
to elicit the individual’s own priorities and perspective. For a more detailed evaluation of specific domains of
functioning, a standard instrument such as the WHO-DAS II may be used together with this interview.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to know about the daily activities that
are most important to you. I would like to better understand how your [PROBLEM] has affected your ability to perform
these activities, and how your family and other people around you have reacted to this.
1. How has your [PROBLEM] affected your ability to do the things you need to do each day, that is, your daily
activities and responsibilities?
2. How has your [PROBLEM] affected your ability to interact with your family and other people in your life?
3. How has your [PROBLEM] affected your ability to work?
4. How has your [PROBLEM] affected your financial situation?
5. How has your [PROBLEM] affected your ability to take part in community and social activities?
6. How has your [PROBLEM] affected your ability to enjoy everyday life?
7. Which of these concerns are most troubling to you?
8. Which of these concerns are most troubling to your family and to other people in your life?

3. Social Network
Related Core CFI Questions: 5, 6, 12, 15
GUIDE TO INTERVIEWER: The following questions identify the influences of the informal social network on the
individual’s problem. Informal social network refers to family, friends and other social contacts through work, places
of prayer/worship or other activities and affiliations. Question #1 identifies important people in the individual’s social
network, and the clinician should tailor subsequent questions accordingly. These questions aim to elicit the social
network’s response, the individual’s interpretation of how this would impact on the problem, and the individual’s
preferences for involving members of the social network in care.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to know more about how your family,
friends, colleagues, co-workers, and other important people in your life have had an impact on your [PROBLEM].
Composition of the individual’s social network

1. Who are the most important people in your life at present?
2. Is there anyone in particular whom you trust and can talk with about your [PROBLEM]? Who? Anyone else?
Social network understanding of problem

3. Which of your family members, friends, or other important people in your life know about your [PROBLEM]?
4. What ideas do your family and friends have about the nature of your [PROBLEM]? How do they understand
your [PROBLEM]?
5. Are there people who do not know about your [PROBLEM]? Why do they not know about your [PROBLEM]?
Social network response to problem

6. What advice have family members and friends given you about your [PROBLEM]?
7. Do your family, friends, and other people in your life treat you differently because of your [PROBLEM]? How
do they treat you differently? Why do they treat you differently?
8. (IF HAS NOT TOLD FAMILY OR FRIENDS ABOUT PROBLEM): Can you tell me more about why you have
chosen not to tell family or friends about the [PROBLEM]? How do you think they would respond if they knew
about your [PROBLEM]?
Social network as a stress/buffer

9. What have your family, friends, and other people in your life done to make your [PROBLEM] better or easier
for you to deal with? (IF UNCLEAR: How has that made your [PROBLEM] better?)
10. What kinds of help or support were you expecting from family or friends?
11. What have your family, friends, and other people in your life done to make your [PROBLEM] worse or harder
for you to deal with? (IF UNCLEAR: How has that made your [PROBLEM] worse?)
Social network in treatment

12. Have any family members or friends helped you get treatment for your [PROBLEM]?
13. What would your family and friends think about your coming here to receive treatment?
14. Would you like your family, friends, or others to be part of your treatment? If so, who would you like to be
involved and how?
15. How would involving family or friends make a difference in your treatment?

4. Psychosocial Stressors
Related Core CFI Questions: 7, 9, 10, 12
GUIDE TO INTERVIEWER: The aim of these questions is to further clarify the stressors that have aggravated the
problem or otherwise affected the health of the individual. (Stressors that initially caused the problem are covered in
the module on Explanatory Models.) In the examples below, the individual’s own words should be used to replace
“[STRESSORS]”. If there are multiple stressors, each relevant stressor can be explored.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: You have told me about some things that make
your [PROBLEM] worse. I would like to learn more about that.
Are there things going on that have made your [PROBLEM] worse, for example, difficulties with family, work,
money, or something else? Tell me more about that.
How are the people around you affected by these [STRESSORS]?
How do you cope with these [STRESSORS]?
What have other people suggested about coping with these [STRESSORS]?
What else could be done about these [STRESSORS]?
GUIDE TO INTERVIEWER: Patients may be reluctant to discuss areas of their life they consider sensitive,
which may vary across cultural groups. Asking specific questions may help the patient discuss these
stressors. Insert questions about relevant stressors here. For example:
6. +ave you experienced discrimination or been treated badly as a result of your background or identity?
By background or identity I mean, for example, the communities you belong to, the languages you
speak, where you or your family are from, your racial or ethnic background, your gender or sexual
orientation, and your faith or religion. Have these experiences had an impact on [STRESSORS] or your
[PROBLEM]?

5. Spirituality, Religion, and Moral Traditions

Related Core CFI Questions: 6, 7, 8, 9, 10, 11, 12, 14, 15
GUIDE TO INTERVIEWER: The following questions aim to clarify the influence of spirituality, religion, and other moral
or philosophical traditions on the individual’s problems and related stresses. People may have multiple spiritual,
moral, and religious affiliations or practices. If the individual reports having specific beliefs or practices, inquire about
the level of involvement in that tradition and its impact on coping with the clinical problem. In the examples below, the
individual’s own words should be used to replace “[NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL
TRADITION(S)]”. If the individual identifies more than one tradition, each can be explored. If the individual does not
describe a specific tradition, use the phrase “spirituality, religion or other moral traditions” instead of the specific name
of a tradition (e.g., Q5: “What role do spirituality, religion or other moral traditions play in your everyday life?”)
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: To help you more effectively, I would like to ask
you some questions about the role that spirituality, religion or other moral traditions play in your life and how they may
have influenced your dealing with the problems that bring you here.
Spiritual, religious, and moral identity

1. Do you identify with any particular spiritual, religious or moral tradition? Can you tell me more about that?
2. Do you belong to a congregation or community associated with that tradition?
3. What are the spiritual, religious or moral tradition backgrounds of your family members?
4. Sometimes people participate in several traditions. Are there any other spiritual, religious or moral traditions
that you identify with or take part in?
Role of spirituality, religion, and moral traditions
5. What role does [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] play in your everyday
life?
6. What role does [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] play in your family, for
example, family celebrations or choices in marriage or schooling?
7. What activities related to [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] do you carry
out in the home, for example, prayers, meditation, or special dietary laws? How often do you carry out these
activities? How important are these activities in your life?
8. What activities do you engage in outside the home related to [NAME(S) OF SPIRITUAL, RELIGIOUS OR
MORAL TRADITION(S)], for example, attending ceremonies or participating in a [CHURCH, TEMPLE OR
MOSQUE]? How often do you attend? How important are these activities in your life?
Relationship to the [PROBLEM]
9. How has [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] helped you cope with your
[PROBLEM]?
10. Have you talked to a leader, teacher or others in your [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL
TRADITION(S)] community, about your [PROBLEM]? How have you found that helpful?
11. Have you found reading or studying [BOOK(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S),
(E.G. BIBLE, KORAN)], or listening to programs related to [NAME(S) OF SPIRITUAL, RELIGIOUS OR
MORAL TRADITION(S)] on TV, radio, the Internet or other media [e.g., DVD, tape] to be helpful? In what
way?
12. Have you found any practices related to [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL
TRADITION(S)], like prayer, meditation, rituals, or pilgrimages to be helpful to you in dealing with
[PROBLEM]? In what way?
Potential stresses or conflicts related to spirituality, religion, and moral traditions
13. Have any issues related to [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] contributed
to [PROBLEM]?
14. Have you experienced any personal challenges or distress in relation to your [NAME(S) OF SPIRITUAL,
RELIGIOUS OR MORAL TRADITION(S)] identity or practices?
15. Have you experienced any discrimination due to your [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL
TRADITION(S)] identity or practices?
16. Have you been in conflict with others over spiritual, religious or moral issues?

6. Cultural Identity
Related Core CFI Questions: 6, 7, 8, 9, 10 Some of the core CFI questionV are repeated below and are marked with
an asterisk (*). The CFI question that is repeated is indicated in brackets.
GUIDE TO INTERVIEWER: This module aims to further clarify the individual’s cultural identity and how this has
influenced the individual’s health and well being. The following questions explore the individual’s cultural identity and
how this may have shaped his or her current problem. We use the word culture broadly to refer to all the ways the
individual understands his or her identity and experience in terms of groups, communities or other collectivities,
including national or geographic origin, ethnic community, racialized categories, gender, sexual orientation, social
class, religion/spirituality, and language.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: Sometimes peoples’ background or identity
influences their experience of illness and the type of care they receive. In order to better help you, I would like to
understand your own background or identity. By background or identity I mean, for example, the communities you
belong to, the languages you speak, where you or your family are from, your racial or ethnic background, your gender
or sexual orientation, and your faith or religion.
National, Ethnic, Racial Background

1. Where were you born?
2. Where were your parents and grandparents born?
3. How would you describe your family’s national, ethnic, and/or racial background?
4. In terms of your background, how do you usually describe yourself to people outside your community?
Sometimes people describe themselves somewhat differently to members of their own community. How do
you describe yourself to them?
5. Which part of your background do you feel closest to? Sometimes this varies, depending on what aspect of
your life we are talking about. What about at home? Or at work? Or with friends?
6. Do you experience any difficulties related to your background, such as discrimination, stereotyping, or being
misunderstood?
7. *Is there anything about your background that might impact on your [PROBLEM] or impact on your health or
health care more generally? [RELATED TO CFI Q#9.]
Language
8. What languages do you speak fluently?
9. What languages did you speak growing up?
10. What languages are spoken at home? Which of these do you speak?
11. What languages do you use at work or school?
12. What language would you prefer to use in getting health care?
13. What languages do you read? Write?
Migration
GUIDE TO INTERVIEWER: If the individual was born in another country, ask questions 1-7. [For refugees, refer to
the module on Immigrants and Refugees to obtain more detailed migration history.]
14. When did you come to this country?

15. What made you decide to leave your country of origin?
16. How has your life changed since coming here?
17. What do you miss about the place or community you came from?
. What are your concerns for your own and your family’s future here?
. What is your current status in this country (e.g., refugee claimant, citizen, student visa, work permit)?
Be aware this may be a sensitive or confidential issue for the individual, if they have precarious status.
20. How has migration influenced your health or that of your family?
21. Is there anything about your migration experience or current status in this country that has made a difference
to your [PROBLEM]?
22. Is there anything about your migration experience or current status that might influence your ability to get the
right kind of help for your [PROBLEM]?

Spirituality, Religion, and Moral Traditions

23. Do you identify with any particular religious, moral or spiritual tradition?
GUIDE TO INTERVIEWER: In the next question, the individual’s own words should be used to replace “[NAME(S)
OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)]”.
24. What role does [NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)] play in your everyday
life?
25. Do your family members share your spiritual, religious or moral traditions? Can you tell me more about that?
Gender Identity
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: Some individuals feel that their gender [e.g. the
social roles and expectations they have related to being male, female, transgender, genderqueer, or intersex]
influences their health and the kind of health care they need.
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26. Do you feel that your [GENDER] has influenced your [PROBLEM] or your health more generally?
27. Do you feel that your [GENDER] has influenced your ability to get the kind of health care you need?
28. Do you feel that health care providers have certain assumptions or attitudes about you or your [PROBLEM]
because of your [GENDER]?

INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: Sexual orientation may also be important to
individuals and their comfort in seeking health care. I would like to ask you some questions about your sexual
orientation. Are you comfortable answering questions about your sexual orientation?
29. How would you describe your sexual orientation (e.g., heterosexual, gay, lesbian, bisexual, queer, pansexual,
asexual)?
30. Do you feel that your sexual orientation has influenced your [PROBLEM] or your health more generally?
31. Do you feel that your sexual orientation influences your ability to get the kind of health care you need for your
[PROBLEM]?
32. Do you feel that health care providers have assumptions or attitudes about you or your [PROBLEM] that are
related to your sexual orientation?
Summary
33. You have told me about different aspects of your background and identity and how this has influenced your
health and well being. Are there other aspects of your identity I should know about to better understand your
health care needs?
34. What are the most important aspects of your background or identity in relation to [PROBLEM]?

7. Coping and Help-Seeking

Related Core CFI Questions: 6, 11, 12, 14, 15 Some of the core CFI questionV are repeated below and are marked
with an asterisk (*). The CFI question that is repeated is indicated in brackets.
GUIDE TO INTERVIEWER: This module aims to clarify the individual’s ways of coping with the current problem. The
individual may have identified the problem as a symptom or mentioned a term or expression (e.g., “nerves,” “being on
edge,” spirit possession), or a situation (e.g., loss of a job), or a relationship (e.g., conflict with others). In the
examples below, the individual’s own words should be used to replace “[PROBLEM]”. If there are multiple problems,
each relevant problem can be explored. The following questions may be used to learn more about the individual’s
understanding and experiencing of that problem.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to understand the problems that bring
you here so that I can help you more effectively. I will be asking you questions about how you have tried to cope with
your problems and get help for them.
Self-coping
1. *Can you tell me more about how you are trying to cope with [PROBLEM] at this time? Has that way of
coping with it been helpful? If so, how? [RELATED TO CFI Q#11.]
2. *Can you tell me more about how you tried to cope with the [PROBLEM] or with similar problems in the past?
Was that way of coping with it helpful? If so, how? [RELATED TO CFI Q#11.]
3. Have you sought help for your [PROBLEM] on the internet, by reading books, by viewing television shows, or
by listening to audiotapes, videos or other sources? If so, which of these? What did you learn? Was it
helpful?
4. Do you engage by yourself in practices related to a spiritual, religious or moral tradition to help you cope with
your [PROBLEM]? For example, prayer, meditation, or other practices that you carry out by yourself?
5. Have you sought help for your [PROBLEM] from natural remedies or medications that you take without a
doctor’s prescription, such as over-the-counter medicines? If so, which natural remedies or medications?
Were they helpful?
Social network
6. *Have you told a family member about your [PROBLEM]? Have family members helped you cope with the
[PROBLEM]? If so, how? What did they suggest you do to cope with the [PROBLEM]? Was it helpful?
[RELATED TO CFI Q#15.]
7. *Have you told a friend or co-worker about your [PROBLEM]? Have friends or co-workers helped you cope
with the [PROBLEM]? If so, how? What did they suggest you do to cope with the [PROBLEM]? Was it
helpful? [RELATED TO CFI Q#15.]
Help- and treatment-seeking beyond social network

8. Are you involved in activities that involve other people related to a spiritual, religious or moral tradition? For
example, do you go to worship or religious gatherings, speak with other people in your religious group or
speak with the religious or spiritual leader? Have any of these been helpful in coping with [PROBLEM]? In
what way?
9. Have you ever tried to get help for your [PROBLEM] from your general doctor? If so, who and when? What
treatment did they give? Was it helpful?
10. Have you ever tried to get help for your [PROBLEM] from a mental health clinician, such as a counselor,
psychologist, social worker, psychiatrist, or other professional? If so, who and when? What treatment did
they give? Was it helpful?
11. Have you sought help from any other kind of helper to cope with your [PROBLEM] other than going to the
doctor, for example, a chiropractor, acupuncturist, homeopath, or other kind of healer? What kind of
treatment did they recommend to resolve the problem? Was it helpful?
Current treatment episode

12. What were the circumstances that led to your coming here for treatment for your [PROBLEM]? Did anyone
suggest you come here for treatment? If so, who, and why did he or she suggest you come here?
13. What help are you hoping to get here [at this clinic] for your [PROBLEM]?

8. Patient–Clinician Relationship
Related Core CFI Question: 16 Some of the core CFI questionV are repeated below and are marked with an asterisk
(*). The CFI question that is repeated is indicated in brackets.
GUIDE TO INTERVIEWER: The following questions address the role of culture in the patient–clinician relationship
with respect to the individual’s presenting concerns and to the clinician’s evaluation of the individual’s problem. We
use the word culture broadly to refer to all the ways the individual understands his or her identity and experience in
terms of groups, communities or other collectivities, including national or geographic origin, ethnic community,
racialized categories, gender, sexual orientation, social class, religion/spirituality, and language.
The first set of questions evaluates four domains in the clinician-patient relationship from the point of view of the
patient: experiences, expectations, communication, and possibility of collaboration with the clinician. The second set
of questions is directed to the clinician to guide reflection on the role of cultural factors in the clinical relationship, the
assessment, and treatment planning.
INTRODUCTION FOR THE PATIENT: I would like to learn about how it has been for you to talk with me and other
clinicians about your [PROBLEM] and your health more generally. I will ask some questions about your views,
concerns, and expectations.
QUESTIONS FOR THE PATIENT:
1. What kind of experiences have you had with clinicians in the past? What was most helpful to you?
2. Have you had difficulties with clinicians in the past? What did you find difficult or unhelpful?
3. Now let’s talk about the help that you would like to get here. Some people prefer clinicians of a similar
background (for example, age, race, religion, or some other characteristic) because they think it may be
easier to understand each other. Do you have any preference or ideas about what kind of clinician might
understand you best?
4. *Sometimes differences among patients and clinicians make it difficult for them to understand each other. Do
you have any concerns about this? If so, in what way? [RELATED TO CFI Q#16.]
GUIDE TO INTERVIEWER: Question #5 addresses the patient-clinician relationship moving forward in treatment.
It elicits the patient’s expectations of the clinician and may be used to start a discussion on how the two of them
can collaborate in the individual’s care.
5. What patients expect from their clinicians is important. As we move forward in your care, how can we best
work together?
QUESTIONS FOR THE CLINICIAN AFTER THE INTERVIEW:
1. How did you feel about your relationship with the patient? Did cultural similarities and differences influence
your relationship? In what way?
2. What was the quality of communication with the patient? Did cultural similarities and differences influence
your communication? In what way?
3. If you used an interpreter, how did the presence of an interpreter or his/her way of interpreting influence your
relationship or your communication with the patient and the information you received?
4. How do the patient’s cultural background or identity, life situation, and/or social context influence your
understanding of his/her problem and your diagnostic assessment?
5. How do the patient’s cultural background or identity, life situation, and/or social context influence your
treatment plan or recommendations?
6. Did the clinical encounter confirm or call into question any of your prior ideas about the cultural background or
identity of the patient? If so, in what way?
7. Are there aspects of your own identity that may influence your attitudes toward this patient?

9. School-Age Children and Adolescents

Related Core CFI Questions: 8, 9, 10
GUIDE TO INTERVIEWER: This supplement is directed to adolescents and mature school-age children. It should be
used in conjunction with standard child mental health assessments that evaluate family relations (including
intergenerational issues), peer relations, and the school environment. The aim of these questions is to identify, from
the perspective of the child/youth, the role of age-related cultural expectations, the possible cultural divergences
between school, home, and the peer group, and whether these issues impact on the situation or problem that brought
the youth for care. The questions indirectly explore cultural challenges, stressors and resilience, and issues of cultural
hybridity, mixed ethnicity or multiple ethnic identifications. Peer group belonging is important to children and
adolescents, and questions exploring ethnicity, religious identity, racism or gender difference should be included
following the child’s lead. Some children may not be able to answer all questions; clinicians should select and adapt
questions to ensure they are developmentally appropriate for the individual. Children should not be used as
informants to provide socio-demographic information on the family or an explicit analysis of the cultural dimensions of
their problems. An Addendum lists cultural aspects of development and parenting that can be evaluated during
parents’ interviews.
INTRODUCTION FOR THE CHILD/YOUTH: We have talked about the concerns of your family. Now I would like to
know more about how you feel about being ___ years old.
Feelings of age appropriateness in different settings
1. Do you feel you are like other children/youth your age? In what way?
2. Do you sometimes feel different from other children/youth your age? In what way?
3. IF THE CHILD/YOUTH ACKNOWLEDGES SOMETIMES FEELING DIFFERENT: Does this feeling of being
different happen more at home, at school, at work, and/or some other place?
4. Do you feel your family is different from other families?
5. Do you use different languages? With whom and when?
6. Does your name have any special meaning for you? Your family? Your community?
7. Is there something special about you that you like or that you are proud of?
Age-related stressors and supports
8. What do you like about being a child/youth at home? At school? With friends?
9. What don’t you like about being a child/youth at home? At school? With friends?
10. Who is there to support you when you feel you need it? At home? At school? Among your friends?
Age-related expectations
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11. What do your parents or grandparents expect from a child/youth your age? (CLARIFY: For example, chores,
schoolwork, play, religious observance.)
12. What do your school teachers expect from a child/youth your age?
13. IF INDIVIDUAL HAS SIBLINGS: What do your siblings expect from a child/youth your age? (CLARIFY: For
example, babysitting, help with homework, dating, dress.)
14. What do other children/youth your age expect from a child/youth your age?
Transition to adulthood/maturity (FOR ADOLESCENTS ONLY)
15. Are there any important celebrations or events in your community to recognize reaching a certain age or
growing up?
16. When is a youth considered ready to become an adult in your family or community?
17. When is a youth considered ready to become an adult according to your school teachers?
18. What is good or difficult about becoming a young woman or a young man in your family? In your school? In
your community?
19. How do you feel about “growing up” or becoming an adult?
20. In what ways are your life and responsibilities different from the life and responsibilities of your parents?

ADDENDUM FOR PARENTS’ INTERVIEW

GUIDE TO INTERVIEWER: Information on cultural influences on development and parenting is best obtained by
interviewing the child’s parents or caretakers. In addition to issues directly related to presenting problems, it is useful
to inquire about:
x The child’s particular place in the family (e.g. oldest boy, only girl)
x The process of naming the child (Who chose the name? Does it have special meaning? Who else is called
like this?)
x Developmental milestones in the culture of origin of the mother (and father): expected age for weaning,
walking, toilet training, speaking. Vision of normal autonomy/dependency, appropriate disciplining and so on
x Perceptions of age-appropriate behaviors (e.g., age for staying home alone, participation in chores, religious
observance, play)
x Child-adult relations (e.g., expression of respect, eye contact, physical contact)
x Gender relations (expectations around appropriate girl-boy behavior, dress code)
x Languages spoken at home, in daycare, at school
x The importance of religion, spirituality, and community in family life and related expectations for the child.

10. Older Adults
Related Core CFI Questions: 5, 6, 7, 8, 9, 10, 12, 13, 15, 16
GUIDE TO INTERVIEWER: The following questions are directed to older adults. The goal of these questions is to
identify the role of cultural conceptions of aging and age-related transitions on the illness episode.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I would like to ask some questions to better
understand your problem and how we can help you with it, taking into account your age and specific experiences.
Conceptions of aging and cultural identity

1. How would you describe a person of your age?
2. How does your experience of aging compare to that of your friends and relatives who are of a similar age?
3. Is there anything about being your age that helps you cope with your current life situation?
Conceptions of aging in relationship to illness attributions and coping

4. How does being older influence your [PROBLEM]? Would it have affected you differently when you were
younger?
5. Are there ways that being older influences how you deal with your [PROBLEM]? Would you have dealt with it
differently when you were younger?
Influence of comorbid medical problems and treatments on illness

6. Have you had health problems due to your age?
7. How have your health conditions or the treatments for your health conditions affected your [PROBLEM]?
8. Are there any ways that your health conditions or treatments influence how you deal with your [PROBLEM]?
9. Are there things that are important to you that you are unable to do because of your health or age?
Quality and nature of social supports and caregiving

10. Who do you rely on for help or support in your daily life in general? Has this changed now that you are going
through [PROBLEM]?
11. How has [PROBLEM] affected your relationships with family and friends?
12. Are you receiving the amount and kind of support you expected?
13. Do the people you rely on share your view of your [PROBLEM]?
Additional age-related transitions

14. Are there other changes you are going through related to aging that are important for us to know about in
order to help you with your [PROBLEM]?
Positive and negative attitudes towards aging and clinician-patient relationship

15. How has your age affected how health providers treat you?
16. Have any people, including health care providers, discriminated against you or treated you poorly because of
your age? Can you tell me more about that? How has this experience affected your [PROBLEM] or how you
deal with it?
17. [IF THERE IS A SIGNIFICANT AGE DIFFERENCE BETWEEN PROVIDER AND PATIENT:] Do you think
that the difference in our ages will influence our work in any way? If so, how?

11. Immigrants and Refugees

Related Core CFI Questions: 7, 8, 9, 10, 13
GUIDE TO INTERVIEWER: The following questions aim to collect information from refugees and immigrants about
their experiences of migration and resettlement. Many refugees have experienced stressful interviews with officials or
health professionals in their home country, during the migration process (which may involve prolonged stays in
refugee camps or other precarious situations), and in the receiving country, so it may take longer than usual for the
interviewee to feel comfortable with and trust the interview process. When patient and clinician do not share a high
level of fluency in a common language, accurate language translation is essential.
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: Leaving one’s country of origin and resettling
elsewhere can have a great impact on people’s lives and health. To better understand your situation, I would like WR
ask you some questions related to your journey here from your country of origin.
Background information
1. What is your country of origin?
2. How long have you been living here in __________ (HOST COUNTRY)?
3. When and with whom did you leave _____________ (COUNTRY OF ORIGIN)?
4. Why did you leave ___________ (COUNTRY OF ORIGIN)?
Pre-migration difficulties
5. Prior to arriving in __________ (HOST COUNTRY), were there any challenges in your country of origin that
you or your family found especially difficult?
6. Some people experience hardship, persecution, or even violence before leaving their country of origin. Has
this been the case for you or members of your family? Can you tell me something about your experiences?
Migration-related losses and challenges

7. Of the persons important/close to you, who stayed behind?
8. Often people leaving a country experience losses. Did you or any of your family members experience losses
upon leaving the country? If so, what are they?
9. Were there any challenges on your journey to __________ (HOST COUNTRY) that you or your family found
especially difficult?
10. Do you or your family miss anything about your way of life in (COUNTRY OF ORIGIN)?
Ongoing relationship with country of origin

11. Do you have concerns about relatives that remain in (COUNTRY OF ORIGIN)?
12. Do relatives in (COUNTRY OF ORIGIN) have any expectations of you?
Resettlement and new life

13. Have you or your family experienced any difficulties related to your visa, citizenship, or refugee status here in
__________ (HOST COUNTRY)?
14. Are there any (other) challenges or problems you or others in your family are facing related to your
resettlement here?
15. Has coming to HOST COUNTRY resulted in something positive for you or your family? Can you tell me
more about that?
Relationship with problem

16. Is there anything about your migration experience or current status in this country that has made a difference
to your [PROBLEM]?
17. Is there anything about your migration experience or current status that might make it easier or harder to get
help for your [PROBLEM]?
Future expectations
18. What hopes and plans do you have for you and your family in the coming years?

12. Caregivers
5HODWHG&RUH&),4XHVWLRQV 6, 12, 14
GUIDE TO INTERVIEWER: This module is designed to be administered to individuals who provide caregiving for the
individual being assessed with the CFI. This module aims to explore the nature and cultural context of caregiving, and
the social support and stresses in the immediate environment of the individual receiving care, from the perspective of
the caregiver.
INTRODUCTION FOR THE CAREGIVER: People like yourself who take care of the needs of patients are very
important participants in the treatment process. I would like to understand your relationship with [INDIVIDUAL
RECEIVING CARE] and how you help him/her with his/her problems and concerns. By help, I mean support in the
home, community, or clinic. Knowing more about that will help us plan his/her care more effectively.
Nature of relationship
1. How long have you been taking care of [INDIVIDUAL RECEIVING CARE]? How did this role for you start?
2. How are you connected to [INDIVIDUAL RECEIVING CARE]?
Caregiving activities and cultural perceptions of caregiving

3. How do you help him/her with the [PROBLEM] or with day-to-day activities?
4. What is most rewarding about helping him/her?
5. What is most challenging about helping him/her?
6. How, if at all, has his/her [PROBLEM] changed your relationship?
Sometimes caregivers like yourself are influenced in doing what they do by cultural traditions of helping
others, such as beliefs and practices in your family or community. By cultural traditions I mean, for example,
what is done in the communities you belong to, where you or your family are from, or among people who
speak your language or who share your race or ethnic background, your gender or sexual orientation, or your
faith or religion.
7. Are there any cultural traditions that influence how you approach helping [INDIVIDUAL RECEIVING CARE]?
8. Is the amount or kind of help you are giving him/her different in any way from what would be expected in the
community that you come from or the one he/she comes from? Is it different from what society in general
would expect?
Social context of caregiving

9. [IF CAREGIVER IS A FAMILY MEMBER:] How do you, as a family, cope with this [PROBLEM]?
10. Are there others, such as family members, friends, or neighbors, who also help him/her with the
[PROBLEM]? If so, what do they do?
11. How do you feel about how much or how little others are helping with his/her [PROBLEM]?
Clinical support for caregiving

12. How do you see yourself helping to provide care to [INDIVIDUAL RECEIVING CARE] now and in the future?
13. [IF UNCLEAR:] How do you see yourself helping with the care that he/she receives in this clinic?
14. How can we make it easier for you to be able to help [INDIVIDUAL RECEIVING CARE] with the
[PROBLEM]?

INDEX
Page numbers printed in boldface refer to tables or figures.
Accreditation Council of Graduate Medical Anxiety, 141–142

Education (ACGME), 254 APA/SAMHSA (American Psychiatric Asso-
Acculturation, 177–178 ciation/Substance Abuse and Mental
failure of, 177 Health Services Administration), 260
stress, 83 Association for American Medical Colleges,
successful, 177–178 253
ACGME (Accreditation Council of Graduate Attention-deficit/hyperactivity disorder
Medical Education), 254 (ADHD), 58
Activities of daily living (ADLs), 69
Addendum for Parents' Interview, 159 Background, 103. See also Cultural Identity
ADHD (attention-deficit/hyperactivity dis- (Supplementary Module 6)
order), 58 Bicultural identity, 83–84
ADLs (activities of daily living), 69 Bisexual, cultural features of the term, 131
Adolescents. See also School-Age Children Bolivia, case vignette of psychosocial stress, 85
and Adolescents (Supplementary Buddhism, 95, 182
Module 9)
eliciting perspectives from, 162 Canada
interviewing, 161–162 development of OCF-related interviews
puberty in, 159 in, 4
in special populations modules, 51, 52 training programs for OCF, 2
African Americans Caregivers (Supplementary Module 12),
case vignette of caregivers, 187 182–190, 313
fear of mental health system, 139–140 description of, 182
roles of religion and spirituality among, domains of assessment, 184
95 family and, 183
Age. See Adolescents; Children; Elderly; guidelines for clinical use of the module,
Older Adults (Supplementary Module 184–188
10) case vignettes, 187
Alcohol abuse, 70–71 overview, 184
American Indians, application of OCF to, 157 rationale for the module, 182–183
American Psychiatric Association/Substance reliance on, 185
Abuse and Mental Health Services role of, 183
Administration (APA/SAMHSA), 260 systems of, 183
315
Case vignettes Children, 33. See also School-Age Children

of caregivers, 187 and Adolescents (Supplementary
of challenges of refugee, 175 Module 9)
of coping and help seeking, 141–142 case vignette interviewing school-age
of cultural competence, 217 children, 160–161
of cultural identity, 115 eliciting perspectives from, 162
of emergencies in emergency depart- OCF and, 4
ments, 210–211 in special populations modules, 51, 52
of field trial experience in Kenya, 242 China, identity and, 109
interviewing school-age children, CL (consultation-liaison psychiatry),
160–161 213–214, 219
of language, 115 Clinician
of level of functioning, 72 awareness of influence of culture on
of migration-related losses and chal- patient, 219
lenges, 175 Continuing Medical Education for,
of psychosocial stressors, 85 261–262
in rural setting, 217 cultural features of the relationship
of spirituality, religion, and moral tradi- between LGBT individuals and clini-
tions, 97 cians, 131–132
Category fallacy, xvii Cultural Formulation Interview–Fidelity
Catholic Church, 95–96, 182 Instrument adherence, 198
CCS (cultural consultation service), 3 Cultural Formulation Interview–Fidelity
CFI. See Cultural Formulation Interview Instrument competence and inter-
CFI–Enhanced Medical Interview, 256 vention distinctiveness, 199
CFI-FI (Cultural Formulation Interview– emotional reactions between patient and,
Fidelity Instrument), 194 147
CFI–Informant Version, xxviii, xxxi, 27–44, empathy from, 85
54, 295–297 “enhancing patient-clinician rapport
assessment in mental health, 42 through satisfaction with the CFI,” 38
clinical situations for use of, 34 ethnocentric bias of, 147
clinician choice of, 34 key themes and implications of cultural
content of the core CFI, 29–32 elements of the relationship between
development of, 28–29, 33–35 the individual and, 11
key findings from the DSM-5 field trial, relationship with individual, 8–9, 17–18,
35–40 50
feasibility, acceptability, and clinical skills, roles, and activities in implementa-
utility subscores, 37 tion and use of CFI, 233–234
main results, 36–40 CME (Continuing Medical Education), 254
overview, 35 Cognition, addressing catastrophic, 64
participating sites by country, 36 Communication, impact of an interpreter on,
study participants, 35–36 151
with older adults, 171 Consultation-liaison (CL) psychiatry,
overview, 27–28 213–214, 219
video illustration of, 30–32 Continuing Medical Education (CME), 254
Chain complexes, 15 for practicing clinicians, 261–262
Index 317
Coping, 136 evidence-based, 275–278

cultural features in LGBT patients, potential mechanisms in, 275
130–131 Cultural Formulation Interview (CFI), xviii
definition of, 142 accreditation standards for mental health
Coping and Help Seeking module (Supple- training programs, 280–281
mentary Module 7), 48, 50, 136–144, 307 administrative perspectives on imple-
case vignette, 141–142 mentation and use, 224–236
description of, 136 concepts for cultural competency, 225
help- and treatment-seeking beyond description of, 224
social network, 140–141 implementation challenges and poten-
importance of assessing, 137–140 tial solutions, 231–234, 234
video illustration 13, xxv, 137–138 organizational routines, proce-
video illustration 14, xxv, 138–140 dures, and practices, 232–233
overview, 140–141 overarching policy, funding, and
self-coping, 140 reporting requirements, 232
social network and, 140 practitioner skills, roles, and activi-
Countertransference, 153. See also Patient- ties, 233–234
Clinician Relationship (Supplementary implementation strategies, 228–231
Module 8) evaluation, 231
cultural aspects of, 147 implementation checklist, 229
Crisis of faith planning, 228–230
video illustration 8, xxiv, 95–96 organizational purpose and need,
Cultural awareness 224–226
in Kenya, 241–242 use and benefits of, 226–228
in The Netherlands, 246 information relevant for clinical
Cultural bereavement, 83 outcomes, 228
Cultural competence, 216–217 scalability and accessibility,
case vignette, 217 227–228
CFI in psychiatric education and, 253–266 standardization, 226–227
concepts for, 225 as an intervention, 11–12, 13–18
definition of, 224, 225 assessment in mental health, 42
Culturally competent system of care barriers to implementing, 40, 41
definition of, 224, 225 CFI–Informant Version, xxxi, 27–44
Cultural consultation service (CCS), 3 clinical choice of, 34
Cultural countertransference, 18 clinical implementation of, xxxi–xxxii,
“Cultural Definition of the Problem” 18–21, 22, 191–207
domain, 29 contexts of use of, 18–19
Cultural explanations, 16 length and content of, 19–20
“Cultural Factors Affecting Current Help training, 20–21
Seeking” domain, 32 in clinical settings, 208–223
“Cultural Factors Affecting Self-Coping and characteristics of, 219
Past Help Seeking” domain, 32 consultation-liaison psychiatry,
Cultural formulation, 267–285 213–214, 219
common themes in, 273 cultural factors affecting current help
in DSM, 267–268 seeking, 214
Cultural Formulation Interview (CFI) (con- proposed CFI–Enhanced Medical

tinued) Interview, 256
in clinical settings (continued) resources for, 256
cultural factors affecting self-coping sample curriculum, 255–256
and past help seeking, 214 regulations and guidelines on teach-
cultural perceptions of cause, context, ing cultural assessment, 253–254
and support, 213–214 culture and, xxx
description of, 208–209 development of, 22, 28–29
emergency departments, 209–212, 219 DSM-5 development of, 22
case vignettes, 210–211 effectiveness of, xxx–xxxi
video illustration 18, xxv, 209–210 exploration of cultural identity and, 116
outpatient settings, 214–216, 219 future of, xxxii, 267–285
technical aspects, 217–218 contrasts between DSM framing of
urban and rural community health disorders and a cultural perspec-
centers, 216–217, 219 tive, 269
case vignette, 217 design dilemmas in CFI, 268–271
components of, xxvii–xxviii, xxxii, 22 evidence-based cultural formulation,
content of the core, 29–32 275–278
video illustration 1, xxiii, 30–31 implementing, 271–272
content of the core domains from interview to formulation, 272–275
“Cultural Definition of the Problem,” common themes in cultural formu-
29 lations, 273
“Cultural Factors Affecting Current cultural formulation grid, 276
Help Seeking,” 32 potential mechanisms in cultural
“Cultural Factors Affecting Self-Cop- formulation, 275
ing and Past Help Seeking,” 32 temporal frames in cultural formu-
“Cultural Perceptions of Cause, Con- lation, 277
text, and Support,” 30 place of culture in DSM, 267–268
contexts of use in, 12, 18–19 promoting use of CFI through training
Core Version, 28–29, 289–293 and continuing education,
cultural competence in psychiatric educa- 280–281
tion and, 253–266 research agenda for CFI, 278–280
adult psychiatric resident education, as a work in progress, 268
257–261 goals of, 45–46
curricula examples of, 260–261 in international settings, 237–251
curriculum requirements for, 259 description of, 237–238
model curricula in cultural psychi- in India, 238–240
atry, 260 in Kenya, 240–243
continuing medical education for in The Netherlands, 243–245
practicing clinicians, 261–262 in Sweden and other Nordic countries,
cultural competence training 245–247
resources for educators, 263 key findings from the DSM-5 field trial,
description of, 253 35–40
medical student education, 254–257 feasibility, acceptability, and clinical
integration, 254–255 utility subscores, 37
Index 319
main results, 36–40 Cultural Formulation Interview–Fidelity

effects on medical communication, Instrument (CFI-FI), 194
37–38, 39 Cultural humility, definition of, 224, 225
feasibility, acceptability and per- Cultural identity
ceived clinical utility of the assessment in the core cultural formula-
core CFI, 36–37, 37 tion interview and supplementary
overview, 35 modules, 118–120
participating sites by country, 36 video illustration 11, xxv, 119–120
study participants, 35–36 definition of, 107
length and content of, 12, 19–20 gender identity and, 123–135
modules, xxviii language and, 113–114
core CFI expansion, xxviii migration and, 114
informant perspectives, xxviii national, ethnic, and racial background
specific populations, xxviii and, 107–117
overview, xxvii–xxxiv, 27–28 sexual orientation identity and, 123–135
planning and assessment, 191–207 spirituality, religion, and moral traditions
action, 195, 196–200 and, 118–122
actors involved in, 194, 195, 196 video illustration 11, xxv, 119–120
amount of intervention, 201, 195 Cultural Identity (Supplementary Module 6),
description of, 191–193 5–6, 13–14, 50, 101–106, 305–306
Fidelity Instrument subscales of clini- ascriptions of identity by others, 13
cal adherence and patient respon- assessment of, 13–14
siveness, 198 clinical presentation and, 14
Fidelity Instrument subscales of clini- conflicts of, 14
cal competence and intervention description of, 101
distinctiveness, 199 from DSM-IV to DSM-5, 101–102
implementation facets of, 14
definition, 191 gender and, 104
outcomes, 195, 201–202, 203 hybridity and, 102
implementation strategies for individ- “hybrid” nature of, 14
uals and teams, 193–204 of the individual, 13–14
description of, 193–194 key themes and implications for DSM-5,
sample implementation strategies, 10
195 language, 103–104, 114–115
justification, 195, 202, 204 case vignette, 115
research-practice gap in, 192 migration, 103–104, 114
target of action, 200 national, ethnic, and racial background,
temporality, 201 103–104, 107–114
questionnaire, 42 overview, 102–104
supplementary modules. See Supplemen- self-defined, 13
tary modules sexual orientation identity and, 104
training, 12, 20–21 socioeconomic status and, 13
types of, xxvii spirituality, religion, and moral tradi-
video illustration of, 30–32 tions, 104
videos of, xxiii–xxv treatment of, 102
Cultural Identity (Supplementary Module 6) Culture-bound syndromes, 16

(continued) Culture brokers, 3
using the model, 114 Curriculum
case vignette of, 115 models for cultural psychiatry, 260–261
Cultural idioms of distress, 16 requirements for adult psychiatric resi-
“Cultural Perceptions of Cause, Context, dent education, 259
and Support” domain, 30 for sample medical student, 255–256
Cultural syndromes, 16
Cultural transference, 18 DCCIS (DSM-5 Cross-Cultural Issues Sub-
Culture group), xxviii–xxix, 28–29
as an explanation of the individual's ill- Decontextualization, 65
ness, 6–7, 14–16 Denmark
attitudes toward, 147 development of OCF-related interviews
CFI and, xxx in, 4
clinician awareness of influence on training programs for OCF, 2
patient, 219 Dhat syndrome, 238
cross-cultural assessment, 179 Disability
as a defense mechanism, 152–153 World Health Organization description
definition of, 224, 225 of, 69
description of, 103 Discrimination, 17
diaspora, 109 perceived, 83
diversity and, 270 Distress
effects of psychological distress, 68–69 conceptualizations among LGBT
elements of the relationship between patients, 125–126
individual and clinician, 8–9, 17–18 cultural background and expression of
ethnocultural minorities, 17 psychological distress, 68–69
factors related to psychosocial environ- cultural concepts of, 57
ment and levels of functioning, 16–17 Dominican Republic, case vignette of coping
of the host, 6 and help seeking, 141–142
key themes and implications for cultural Dr. Ram Manohar Lohia Hospital, 238
factors related to psychosocial envi- DSM-IV
ronment and levels of functioning, 11 cultural identity to DSM-5, 101–102
key themes and implications for explana- Outline for Cultural Formulation, 22
tions of the individual's illness, 10 DSM-5
local moral worlds and, xvii CFI development of, 22
overview, xxvii–xxxiv cultural identity from DSM-IV, 101–102
of patient's environment, 84 culture formulation before, xxxi, 1–26
pitfall, 152 future of CFI
place in DSM, 267–268 contrasts between DSM framing of
psychosocial stressors and, 81–84 disorders and a cultural perspec-
role of reflection in, 148 tive, 269
social networks and, 75–76 key findings from the field trial, 35–40, 42
stereotyping, 218 main results, 36–40
values and, 86
Index 321
barriers to implementing the core EMIC (Explanatory Model Interview Cata-

CFI in clinical practice, 38, 40, 41 logue), 4, 57–58
CFI's effects on medical communi- Emotions, reactions between patients and
cation, 37–38, 39 clinicians, 147
feasibility, acceptability, and per- Empathy, 63
ceived clinical utility of the from the clinician, 85
core CFI, 36–37, 36 Ethnicity
overview, 35 conflicts between ethnic groups, 110
study participants, 35–36, 36 Cultural Identity (Supplementary
key themes and implications Module 6), 103–104, 107–114
of cultural elements of the relationship identity and, 109–110
between the individual and the psychosocial stressors and, 83
clinician, 11 Ethnocultural minorities, 17
of cultural explanations of the individ- Europe, identity and, 108
ual's illness, 10 Expansion modules, 49–50, 52
of cultural factors related to psychoso- Explanatory Model (Supplementary
cial environment and levels of Module 1), 49–50, 56–58, 300
functioning, 11 bridging, 59–60, 62–63
of cultural identity of the individual, 10 causal explanations, 60–61
place of culture in, 267–268 course of illness, 61–62
standardization of qualitative method of general understanding of the problem, 58
CFI assessment, 235 help seeking and treatment expectations,
standard training protocol for the CFI, 62
20–21 history of, 56
DSM-5 Cross-Cultural Issues Subgroup illness prototypes, 58–59
(DCCIS), xxviii–xxix, 28–29 importance of assessing patients' explan-
Dynamism error, 46 atory models, 62–64
addressing catastrophic cognitions, 64
Education. See also Training addressing stigmatization, 64
for adult psychiatric residents, 257–261 building empathy and therapeutic
Continuing Medical Education, 261–262 alliance, 63
cultural competence training resources increasing positive expectancy, 63
for educators, 263 maximizing treatment engagement
for medical students, 254–257 and adherence, 62–63
promoting use of CFI through training measures to assess, 57–58
and continuing education, 280–281 overview, 56–57
Elderly. See also Older Adults (Supplemen- variances in, 57
tary Module 10) video illustration 2, xxiv, 58–59
function of, 69 video illustration 3, xxiv, 60
OCF and, 4 video illustration 4, xxiv, 60–61
in special populations modules, 51, 52 Explanatory Model Interview Catalogue
Emergency departments, 209–212 (EMIC), 4, 57–58
case vignettes, 210–211 Explanatory Model module, 48
video illustration 18, xxv, 209–210 Explanatory models, xvii, 4
Family. See also Caregivers (Supplementary Homeless populations, OCF and, 4

Module 12) Homosexual, cultural features of the term, 131
adverse influence on mental health of HOPE, 91. See Spirituality, Religion, and
patient, 185 Moral Traditions (Supplementary
as caregivers, 188 Module 5)
fragmentation of, 81 Hybridity, 102
interactions with patient, 70
psychosocial stressors and, 81 ICD (International Classification of Dis-
response to caregivers, 183 eases), 237, 246
video illustration 6, xxiv, 77–78 Identity. See also Cultural identity; Spiritual-
FICA, 91. See Spirituality, Religion, and Moral ity, Religion, and Moral Traditions
Traditions (Supplementary Module 5) (Supplementary Module 5)
bicultural, 83–84
Gay, bisexual, and transgender (GBT) indi- definition of, 101
viduals, 96 ethnicity and, 109–110
Gay, cultural features of the term, 131 geopolitical origins and, 108–109
GBT (gay, bisexual, and transgender) indi- national, 107–109
viduals, 96 place of birth and, 108
Gender, definition of, 123–124 racial and “racialized” identity, 110–114
Gender identity. See also Lesbian-gay- video illustration 9, xxiv, 111–112
bisexual-transgender individuals video illustration 10, xxv, 112
awareness of, 125 spiritual, religious, and moral, 93–94
conceptualizations of distress among Idioms of distress, 16, 30, 48
LGBT patients, 125–126 Illness
cultural identity and, 123–135 course of, 61–62
Cultural Identity (Supplementary effect of cultural factors on, 188
Module 6) and, 104 explanatory models of, 139
description of, 123 models of, 15
relationship of spirituality, religion, and prototypes of, 15, 59
moral traditions to, 120–121 representations of, 15
God. See Spirituality, Religion, and Moral Immigrants, 48. See also Immigrants and Ref-
Traditions (Supplementary Module 5) ugees (Supplementary Module 11)
Greece, case vignette of level of functioning, 72 mental health among, 179
Guatemala, video illustration of interview in OCF and, 4
an emergency department, 209–210 psychosocial stressors and, 83
Guidelines for Six Core Competencies, 254 social networks and, 78
in special populations modules, 51
Healing, 139 Immigrants and Refugees (Supplementary
Help seeking, 136 Module 11), 173–181
classification of, 136 assessment challenges, 178–179
cultural features in LGBT patients, description of, 173
130–131 overview of the supplementary module,
definition of, 142 173–178
HNCH (National Hospital Cayetano Here- background information, 173–174
dia), 214–216 future expectations, 178
Index 323
migration-related losses and chal- field trial, 242

lenges, 175–176 case vignette, 242
case vignette, 175 local need for cultural awareness,
video illustration 9, xxiv, 175–176 241–242
ongoing relationship with country of summary of, 243
origin, 177 Kenyatta National Hospital/University of
premigration difficulties, 174–175 Nairobi, 241
relationship with clinical problem, 178
resettlement and new life, 177 Language, 5
Independence-interdependence, 82 case vignette, 115
India, 69 Cultural Identity (Supplementary
case vignette of caregivers, 187 Module 6) and, 103–104, 113–114
CFI experience in, 238–240 fluency in, 113–114
description of, 238–239 Legislation
field trial, 239–240 Maintenance and Welfare of Parents and
clinicians, 240 Senior Citizens Act (2007), 69
participants, 239–240 Lesbian, cultural features of the term, 131
summary of, 240 Lesbian-gay-bisexual-transgender (LGBT)
dhat syndrome in, 238 individuals, 17
training programs for OCF, 2 conceptualizations of distress among,
Individualism-collectivism continuum, 82, 86 125–126
Informant perspectives module, 52–53 cultural features of coping and help seek-
decision tree, 47 ing among, 130–131
Insomnia, 141–142 cultural features of the relationship
Intercultural contact stress, 83 between LGBT individuals and clini-
International Classification of Diseases cians, 131–132
(ICD), 237, 246 psychiatric diagnosis of, 128–129
Interpreters psychosocial stressors and cultural fea-
in child psychiatry, 157 tures of vulnerability in, 126–130
impact on communication, 151 video illustration 12, xxv, 129–130
in intercultural clinical work, 212 religion and spirituality among, 96
relationship with, 272 Level of Functioning (Supplementary
Interrater reliability, 197 Module 2), 68–74, 301
Iran case vignettes, 72
case vignette of challenges of refugee, 175 description of, 68
cultural identity and, 113 effect of culture and society on, 73
Iraq guidelines for clinical use of, 71–72
case vignette, 115 overview, 69–70
cultural identity and, 108 rationale for, 68–69
video illustration 5, xxiv, 70–71
Jewish General Hospital, 3, 272–273, 273 LGBT (lesbian-gay-bisexual-transgender)
individuals, 17
Kenya Liaison Committee on Medical Education,
CFI experience in, 240–243 253–254
description of, 240–241 Liaison Old Age Psychiatry (LOAP), 213
Literacy, OCF and, 4 Montreal CCS interview, 18, 19

LOAP (Liaison Old Age Psychiatry), 213 Morality, 49. See also Spirituality, Religion,
Loneliness, 69 and Moral Traditions (Supplementary
Module 5)
Main effects model, 76 cultural identity and, 118–122
Maintenance and Welfare of Parents and definition of, 90–91
Senior Citizens Act (2007), 69 gender identity and, 120–121
Mathari National Teaching and Referral video illustration 11, xxv, 119–120
Hospital, 241
McGill Illness Narrative Interview (MINI), 4, National Hospital Cayetano Heredia
57–58 (HNCH), 214–216
McGill University, 261 National identity, 107–109
Medical communication, 37–38, 39, 42 National Institutes of Health (NIH), 191–192
Meditation, 95 National Norwegian Center for Minority
Medscape, 261 Health Research, 247
Men, spiritual and religious factors among, National Standards for Culturally and Lin-
96 guistically Appropriate Services in
Mental health Health and Health Care, 225
accreditation standards for mental health Nervios, 85, 87
training programs, 280–281 The Netherlands
adverse influence of family of patient, 185 CFI experience in, 243–245
fear of, 139–140 description of, 243–244
global challenge of, 237–238 field trial, 244
international assessment, 69 summary of, 244–245
social networks and, 75–76 development of OCF-related interviews
social support outcomes and, 76 in, 4
value of a positive patient-clinical rela- training programs for OCF, 2
tionship, 145 New York State Center of Excellence for
Migration, 173–174. See also Immigrants and Cultural Competence, 20
Refugees (Supplementary Module 11) New York State Office of Mental Health, xxii
age at, 174 NIH (National Institutes of Health), 191–192
asylum procedure, 114 Norway, training programs for OCF, 2
Cultural Identity (Supplementary Mod-
ule 6), 103–104, 114 OCF (Outline for Cultural Formulation),
cultural identity and, 114 xxvii–xxviii, 28
involuntary, 174 Older adults. See Elderly; Older Adults
ongoing relationship with country of ori- (Supplementary Module 10)
gin, 177 cultural competence in working with, 171
permanent, 174 cultural influences on diagnose of, 166
temporary, 174 demographics, 165
voluntary, 174 life expectancy of, 165–166
MINI (McGill Illness Narrative Interview), 4, medical conditions in, 171
57–58 Older Adults (Supplementary Module 10),
Modules. See Supplementary modules 165–172, 311–312
Moi Teaching and Referral Hospital, 241 description of, 165
Index 325
guidelines for clinical use of CFI compo- emotional reactions between clinician
nents, 169–170 and, 147
core CFI, 169–170 “enhancing patient-clinician rapport
CFI–Informant Version, 170 through satisfaction with the CFI,”
older adults supplementary module, 38
170 exploring identity of, 98
overview, 167–169 help seeking and treatment expectations,
video illustration 16, xxv, 168 62
video illustration 17, xxv, 169 ideas about the causes of the problem, 65
rationale for, 165–167 illness experience of, 16–17
Organizational cultural competence influence of culture on, 16
definition of, 224, 225 interactions with family, 70
Outline for Cultural Formulation (OCF), level of functioning, 49
xxvii–xxviii, xxix, 28 perception of stress, 85
conceptual framework for, 22 relationship with clinician, 17–18, 50
cultural framework of, 2–4 religious, spiritual, and more beliefs, val-
description of, 2–4 ues, and practices, 98
development of interviews prior to DSM-5, video illustration 7 for preferences for
4, 5–10 care, xxiv, 92–93
diagnostic utility of, 3 Patient-Clinician Relationship (Supplemen-
domains for, 22 tary Module 8), 145–155, 308
before DSM-5, xxxi, 1–26 clinical utility of assessing, 145–148
in DSM-IV, 22 clinical encounter models, 147
goals of, 2 cultural aspects of clinical encounter,
implementation, 22 146–147
key themes related to CFI as an interven- emotional reactions between patients
tion, 11–12, 13–18 and clinicians, 147
overview, 1–2 role of reflection in understanding cul-
use of, 3 ture, 148
description of, 145
Pakistan, psychosocial stressors and, 84 obstacles and caveats when using the
Patients module, 152–153
adherence to treatment, 65 overview, 149–152
clarification of level of impairment, 73 video illustration 2, xxiv, 149–150
cultural elements of the relationship video illustration 15, xxv, 150–151
between clinician and, 8–9, 17–18 stages of, 146
cultural features of the relationship why and when to use the module,
between LGBT individuals and clini- 148–149
cians, 131–132 Peru
Cultural Formulation Interview–Fidelity case vignette of rural community health
Instrument responsiveness, 198 center, 217
disabilities and, 17 field trial, 215–216
education and implementation of treat- National Hospital Cayetano Heredia,
ment plans, 39 214–216
PGIMER (Post-Graduate Institute of Medi- RAMS (Richmond Area Multi-Services),

cal Education and Research), 238 225–226, 227–228
Post-Graduate Institute of Medical Educa- Reflection, role in understanding culture, 148
tion and Research (PGIMER), 238 Reflexive stance, 148
Postpartum depression, 77–78 Reflexivity, 148
Posttraumatic stress disorder (PTSD), 93 Refugees, 48, 147. See also Immigrants and
case vignette, 97 Refugees (Supplementary Module 11)
Psychiatry case vignettes
consultation-liaison in clinical settings, of challenges of, 175
213–214, 219 interviewing school-age children,
cultural competence with CFI in educa- 160–161
tion, 253–266 description of, 174
cultural formulation in child and adoles- mental health among, 179
cent, 156–158 OCF and, 4
interpreter in child psychiatry, 157 psychosocial stressors and, 83
Psychiatry Milestone Project, 20–21, 254 resettlement, 177–178
Psychosocial environment, 16–17 in special populations modules, 51
cultural factors related to, 8 Religion, 15, 49, 79. See also Spirituality, Reli-
Psychosocial stressors gion, and Moral Traditions (Supple-
cultural features of vulnerability in LGBT mentary Module 5)
patients, 126–130 as a coping strategy, 139
in LGBT patients cultural identity and, 118–122
video illustration 12, xxv, 129–130 definition of, 90
Psychosocial Stressors (Supplementary gender identity and, 120–121
Module 4), 49, 81–89, 303 video illustration 11, xxv, 119–120
case vignette, 85 Resettlement, 177–178
culture and, 81–84 Richmond Area Multi-Services (RAMS),
description of, 81 225–226, 227–228
guidelines for clinical use of the module, implementation of CFI, 234
84–86
overview, 84 School-Age Children and Adolescents (Sup-
types of, 87 plementary Module 9), 156–164, 309–310
PTSD (posttraumatic stress disorder), 93 Addendum for Parents' Interview, 159
Puberty, 159 cultural formulation and systemic inter-
actions, 162
Quality Interactions, 261 cultural formulation in child and adoles-
Quality of life, health-related, 69 cent psychiatry, 156–158
description of, 156
Race interviewing adolescents, 161–162
Cultural Identity (Supplementary Mod- interviewing school-age children, 160–161
ule 6) and, 103–104, 107–114 case vignette, 160–161
psychosocial stressors and, 83 principles in application of, 158
stressors and, 17 use in child and adolescent psychiatry,
Racism, institutional, 162 158–160
Index 327
Self-coping, 140 gender identity and, 120–121

Self-reflection, maintaining, 148 video illustration 11, xxv, 119–120
Sexual behavior, 124 Spirituality, Religion, and Moral Traditions
Sexual minorities, psychosocial stressors (Supplementary Module 5), 90–100, 304
and, 83 case vignette, 97
Sexual orientation identity. See also Lesbian- cultural identity and, 104
gay-bisexual-transgender individuals description of, 90–91
awareness of, 125 for exploring a patient's identity, 98
cultural identity and, 123–135 guidelines for clinical use of the module,
Cultural Identity (Supplementary 97
Module 6) and, 104 importance of assessing, 91–93
spirituality, religion, and moral traditions video illustration 7, xxiv, 92–93
and, 120–121 overview, 93–96
Social networks, for coping and help seek- relationship to the problem, 94–95
ing, 140–141 role in assessing suicide, 93
Social Networks (Supplementary Module 3), role in the individual's life, 94
49, 75–80, 186, 302 spiritual, religious, and moral identity,
culture and, 75–76 93–94
description of, 75 stresses or conflicts related to, 95–96
domains of, 77–78 video illustration 8, xxiv, 95–96
guidelines for clinical use of the module, Stereotyping, 218, 255, 258
78–79 Stigmatization
main effects model, 76 addressing, 64
mental health and, 75–76 toward mental health, 140
overview, 76–78 Stress, patient's perception of, 85
stress-buffering model, 76 Stress-buffering model, 76
video illustration 6, xxiv, 77–78 Stressors. See also Psychosocial Stressors
Social support, 79. See also Social Networks (Supplementary Module 4)
(Supplementary Module 3) asking relevant questions about, 86
mental health outcomes and, 76 assessment of, 17
Socioeconomic status (SES) psychosocial, 49
cultural identity and, 13 in LGBT patients, 126–130
low, 17 video illustration 12, xxv, 129–130
Spain, training programs for OCF, 2 race and, 17
Special populations modules, 51, 52 Substance use, 70–71
decision tree, 47 Suicide, role in assessing, 93
SPIRIT, 91. See also Spirituality, Religion, Supplementary modules, xxviii, xxxi, 54
and Moral Traditions (Supplementary 1: Explanatory Model, 56–68, 300
Module 5) 2: Level of Functioning, 68–74, 301
Spirituality, 49. See also Spirituality, Reli- 3: Social Networks, 75–80, 302
gion, and Moral Traditions (Supple- 4: Psychosocial Stressors, 81–89, 303
mentary Module 5) 5: Spirituality, Religion, and Moral Tradi-
cultural identity and, 118–122 tions, 90–100, 304
definition of, 90 6: Cultural Identity, 101–106, 305–306
description of, 118 7: Coping and Help Seeking, 136–144, 307
Supplementary modules (continued) key themes and implications for DSM-5,

8: Patient-Clinical Relationship, 145–155, 12
308 programs for OCF, 2–3
9: School-Age Children and Adolescents, promoting use of CFI through training
156–164, 309–310 and continuing education, 280–281
10: Older Adults, 165–172, 311 of staff, 230
11: Immigrants and Refugees, 173–181, supplementary modules and, 46, 48
312 Transcultural Center of the Stockholm
12: Caregivers, 182–190, 313 County Council, 247
clinical work, 46, 48 Transference, 153. See also Patient-Clinician
core CFI expansion, xxviii Relationship (Supplementary Module 8)
decision tree for evaluations, 47 cultural aspects of, 147, 179
expansion modules, 49–50, 52 Transgender, cultural features of the term,
guidelines for implementing, 299–313 131
informant perspectives, xxviii, 52–53 Translators, 226, 233
overview, 45–46 Treatment, maximizing engagement and
research, 46, 48 adherence, 62–63
special populations modules, 51, 52 Tribe, 109. See also Ethnicity; Identity
specific populations, xxviii Turkey, case vignette of level of functioning,
structure of, 53 72
training, 46, 48
types of, 46, 47, 48, 52–53, 54 UCD (University of California Davis),
Sweden 255–256
CFI experience in, 245–247 United Kingdom
description of, 245–246 development of OCF-related interviews
DSM-IV and, 246–247 in, 4
local need for cultural awareness, 246 training programs for OCF, 3
summary of, 247 United States
development of OCF-related interviews development of OCF-related interviews
in, 4 in, 4
training programs for OCF, 2 training programs for OCF, 3
University of California Davis (UCD),
Team PEACE (Teamwork for Professional- 255–256
ism, Ethics, and Cultural Competence Urban and rural community health centers,
Enrichment), 255–256, 257 216–217, 219
Teamwork for Professionalism, Ethics, and U.S. Office of Minority Health, 261
Cultural Competence Enrichment
(Team PEACE), 255–256, 257 Videos
Temporality, 201 of the core CFI, 30–32
Training. See also Education credits for, xxvi
of CFI, 20–21, 196–197 descriptions of, xxiii–xxv. See also indi-
cultural competence training resources vidual videos
for educators, 263 guide to, xxiii–xxvi, xxxii
developing a standard protocol for, 20 learning experience of, xxiii
guidance on, 19 use of, xxiii
Index 329
video illustration 1, xxiii, 30–31 video illustration 17, xxv, 169

video illustration 2, xxiv, 58–59, 149–150 video illustration 18, xxv, 209–210
video illustration 3, xxiv, 60
video illustration 4, xxiv, 60–61 WHO (World Health Organization), 69
video illustration 5, xxiv, 70–71 WHODAS (World Health Organization Dis-
video illustration 6, xxiv, 77–78 ability Assessment Schedule), 71–72
video illustration 7, xxiv, 92–93 Women
video illustration 8, xxiv, 95–96 postpartum depression in, 77–78
video illustration 9, xxiv, 111–112, 175–176 roles of religion and spirituality among, 95
video illustration 10, xxv, 112 selfhood, 82
video illustration 11, xxv, 119–120 World Health Organization (WHO), 69
video illustration 12, xxv, 129–130 World Health Organization Disability
video illustration 13, xxv, 137–138 Assessment Schedule (WHODAS),
video illustration 14, xxv, 138–140 71–72
video illustration 15, xxv, 150–151
video illustration 16, xxv, 168 Youth. See Adolescents

DSM-5® Handbook On The Cultural Formulation Interview

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DSM-5® Handbook On The Cultural Formulation Interview

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Roberto Lewis-Fernández, M.D., M.T.S.

1 Cultural Formulation Before DSM-5 . . . . . . . . . . . . . 1

2 The Core and Informant Cultural Formulation

Supplementary Module 10:

Supplementary Module 11:

Use of the Cultural Formulation

Administrative Perspectives on the

Application of the Cultural Formulation

5 Cultural Competence in Psychiatric Education

Iqbal Ahmed, M.D.

Renato D. Alarcón, M.D., M.P.H.

Tichianaa Armah, M.D.

Sofie Bäärnhielm, M.D., Ph.D.

Kavoos Ghane Bassiri, M.S., LMFT, LPCC, CGP

Triptish Bhatia, Ph.D.

James Boehnlein, M.D., M.Sc.

Francisco Collazos, M.D.

Lizardo Cruzado, M.D.

Smita Neelkanth Deshpande, M.D., D.P.M.

Ravi DeSilva, M.D., M.A.

Esperanza Díaz, M.D.

Irene Falgàs, M.D.

David M. Gellerman, M.D., Ph.D.

Simon Groen, M.A.

Jaswant Guzder, M.D.

Rita Hargrave, M.D.

Mark L. Hatzenbuehler, Ph.D.

Devon E. Hinton, M.D., Ph.D.

Ladson Hinton, M.D.

Sushrut Jadhav, M.B.B.S., M.D., MRCPsych, Ph.D.

Oscar Jiménez-Solomon, M.P.H.

Laurence J. Kirmayer, M.D.

Arthur Kleinman, M.D.

Peter C. Lam, M.P.H.

Martin La Roche, Ph.D.

Roberto Lewis-Fernández, M.D., M.T.S.

Russell F. Lim, M.D., M.Ed.

Francis G. Lu, M.D.

K. Musa Misiani, B.Sc. Hons

Abednego M. Musau, M.B.Ch.B.

Victoria M. Mutiso, M.Sc., Ph.D.

Rhodah Mwangi, B.A.

David M. Ndetei, M.B.Ch.B., D.P.M., MRCPsych, FRCPsych, M.D., D.Sc.

Vishwajit Laxmikant Nimgaonkar, M.D., Ph.D.

John E. Pachankis, Ph.D.

Adil Qureshi, Ph.D.

Hans Rohlof, M.D.

Cécile Rousseau, M.D.

Monica Scalco, M.D., Ph.D.

Angela Tang Soriano, M.S.S.W., LCSW

Rob van Dijk, M.Sc.

Hendry Ton, M.D., M.S.

Johann Vega-Dienstmaier, M.D.

Mitchell G. Weiss, M.D., Ph.D.

Joseph Westermeyer, M.D., Ph.D.

Disclosure of Competing Interests

Roberto Lewis-Fernández, M.D.—Research support: Principal Investigator of an

Neil Krishan Aggarwal, M.D., M.B.A., M.A.

In the 1970s, when I began my research and writing, cultural psychiatry as

Explanatory Model supplementary module explicitly asks patients about changes in

Arthur Kleinman, M.D.