“I Got to Voice What’s in My Heart”: Participation in the Cultural Formulation Interview—Perspectives of Consumers with Psychotic Disorders

What information did the DSM-5 Cultural Formulation Interviews provide when used with Swedish-speaking patients in a psychiatric setting in Stockholm?

Introduction

Cultural and contextual factors affect communication and how psychiatric symptoms are presented, therefore psychiatric assessments need to include awareness of the patients' culture and context. The Cultural Formulation Interview (CFI) in DSM-5 is a person-centred tool developed to support the exploration of cultural and contextual factors in an individualized and non-stereotypic way.

Methods

The aim of this qualitative study was to find out what information the DSM-5 CFI revealed when used with native Swedish-speaking patients as part of routine clinical psychiatric assessment at an outpatient clinic. An additional aim was to enhance understanding of what kind of information the questions about background and identity yielded. The CFI was added to the psychiatric assessment of 62 native Swedish-speaking patients at an outpatient psychiatric clinic in Stockholm.

Results

From the thematic analysis of the documented CFI answers, six central themes were found; Descriptions of distress and dysfunction, Managing problems and distress, Current life conditions affecting the person, Perceived failure in meeting social expectations, Making sense of the problem, and Experiences of, and wishes for, help. The CFI questions about identity yielded much information, mainly related to social position and feelings of social failure.

Discussion

For further refinement of the CFI, we see a need for re-framing the questions about cultural identity and its impact on health so that they are better understood. This is needed for majority population patients as direct questions about culture may be difficult to understand when cultural norms are implicit and often unexamined. For clinical implications, our findings suggest that for cultural majority patients the DSM-5 CFI can be a useful person-centred tool for exploring cultural and, in particular, social factors and patients' perception and understanding of distress.

A qualitative analysis of the documentation of DSM-5 Cultural Formulation Interviews with non-native speaking patients in a Swedish mental health care setting

Introduction

Cultural variety in expressed symptom presentations of mental health problems creates difficulties in transcultural diagnostic assessments. This emphasizes the need of culturally sensitive diagnostic tools like the Cultural Formulation Interview (CFI). Although the CFI is being implemented worldwide there is a lack of studies analyzing what kind of information it provides when used with new patients in routine psychiatric assessments, and how CFI information contributes to diagnostic evaluations. This study aimed to find out what information the CFI questions revealed when used with non-native Swedish speaking patients. We also wanted to understand how the CFI may facilitate identification of psychiatric diagnoses among these patients.

Materials and methods

The CFI was used as part of a routine clinical psychiatric assessment in an outpatient clinic in Sweden. Interpreters were used in the consultations when needed. A qualitative thematic analysis was used to analyze the documented CFI answers from non-native speaking patients.

Results

We found that the CFI information contained contextualized descriptions of dysfunction and current life conditions, as well as expressions of emotions, often described along with somatic terms.

Discussion

Our results indicate that the narrative approach of the CFI, giving contextualized information about distress and functioning, can facilitate clinicians' identification of psychiatric symptoms when language, psychiatric terms and understandings are not shared between patient and clinician.

Unlocking asylum seekers' voices: protocol of a mixed-method clinical study on the use of the cultural formulation interview with asylum seekers in Belgium

Background

Despite a high prevalence of mental disorders among asylum seekers, many barriers to mental healthcare exist. Cultural and contextual factors strongly influence the experience and expression of psychological distress, putting asylum seekers at greater risk of misdiagnosis and inappropriate treatment. The Cultural Formulation Interview (CFI) is a useful tool to map out cultural and contextual factors of mental disorders; however, to the best of our knowledge, it has not yet been investigated in asylum seekers specifically. The primary aim of this study is to evaluate the value of the CFI in the psychiatric assessment of asylum seekers. Second, we will describe the themes relevant to psychiatric distress in asylum seekers that are identified by the CFI. In addition, asylum seekers' experience of the CFI will be evaluated.

Methods and analysis

This cross-sectional, mixed-method clinical study aims to recruit a group of 60-80 asylum seekers (age 15-29) with mental health symptoms. Data will be collected using structured (MINI, PCL-5, HDRS-17, WHOQoL-BREF & BSI) and semi-structured (CFI & CFI-debriefing) questionnaires to assess cultural background, contextual factors, and illness severity. Multidisciplinary case discussions will be held after the completion of interviews, following a methodological stepped approach. Combining qualitative and quantitative research techniques, this study aims to generate reliable knowledge on working with the CFI in asylum seekers. Based on the findings, recommendations for clinicians will be developed.

Discussion

This study addresses the knowledge gap on using the CFI in asylum seekers. Compared to prior studies, it will provide new insights into the use of the CFI in the specific context of working with asylum seekers.

Ethics and dissemination

Prior research on the CFI in asylum seekers is limited, partly because of their high vulnerability and low access to care. The study protocol has been tailored in close collaboration with several stakeholders and validated after piloting. Ethical approval has already been obtained. Together with the stakeholders, the results will be translated into guidelines and training materials. Recommendations to policymakers will also be provided.

Health professionals interface with cultural conflict in the delivery of type 2 diabetes care

OBJECTIVE

This study explored the knowledge and experiences of health professionals (HPs) caring for South Asian patients with type 2 diabetes (T2D).

DESIGN

Fourteen HPs, who supported patients with T2D, were interviewed. The recruitment strategy employed purposeful and theoretical sampling methods to recruit HPs who worked across primary and secondary care settings.

MAIN OUTCOME MEASURES

Grounded Theory (GT) methodology and analysis generated a theoretical framework that explored HP's perceptions and experiences of providing diabetes care for South Asian patients.

RESULTS

A GT, presenting a core category of Cultural Conflict in T2D care, explores the influences of HP's interactions and delivery of care for South Asian patients. This analysis is informed by four categories: (1) Patient Comparisons: South Asian vs White; (2) Recognising the Heterogeneous Nature of South Asian Patients; (3) Language and Communication; (4) HPs' Training and Experience.

CONCLUSIONS

The findings consider how the role of social comparison, social norms, and diminished responsibility in patient self-management behaviours influence HPs' perceptions, implicit and explicit bias towards the delivery of care for South Asian patients. There was a clear call for further support and training to help HPs recognise the cultural-ethnic needs of their patients.

The Cultural Formulation Interview-Generating distance or alliance? A qualitative study of practice changes in Danish mental healthcare

This article presents provider experiences with the Cultural Formulation Interview (CFI) in Danish mental healthcare for migrant patients. Semi-structured interviews with 17 providers and 20 recorded CFI sessions were analyzed with a constructivist grounded theory approach. Based on our empirical material, we endorse the CFI's ability to facilitate working alliance and a profound and contextually situated understanding of the patient. Further, the CFI supported less-experienced providers in investigating cultural issues. Conversely, we found that CFI questions about cultural identity and background evoked notions of distance and 'othering' in the encounter. Nine providers had felt discomfort and professional insecurity when the CFI compelled them to introduce explanatory frameworks of culture in the mental health assessment. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which had limited analytical value. We describe the contradictory CFI experiences of alliance versus distance at three levels: 1) at the CFI instrument level; 2) at the organizational level; and 3) at the contextual and structural level. We demonstrate benefits and pitfalls of using the CFI with migrants in Denmark, which is an example of a European healthcare context where cultural consultation is not an integrated concept in health education programs and where the notion of culture is contentious due to negative political rhetoric on multiculturalism.We suggest that the CFI should be introduced with thorough training; focus on fidelity; and supervision in the clinical application and understanding of the concept of culture.

Negotiating Engagement, Worthiness of Care and Cultural Identities Through Intersubjective Recognition: Migrant Patient Perspectives on the Cultural Formulation Interview in Danish Mental Healthcare

This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.

The Cultural Formulation Interview: Progress to date and future directions

The Cultural Formulation Interview (CFI) developed for DSM-5 provides a way to collect information on patients' illness experience, social and cultural context, help-seeking, and treatment expectations relevant to psychiatric diagnosis and assessment. This thematic issue of Transcultural Psychiatry brings together articles examining the implementation and impact of the CFI in diverse settings. In this editorial introduction we discuss key areas raised by these and other studies, including: (1) the potential of the CFI for transforming current psychiatric assessment models; (2) training and implementation strategies for wider application and scale-up; and (3) refining the CFI by developing new modules and alternative protocols based on further research and clinical experience.

Patients' and clinicians' experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting

This study is an evaluation of clinicians' and patients' experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians (N = 15) and a revised version of the Debriefing Instrument for Patients (N = 114) (DIC and DIP, scored from -2 to 2). Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD = 0.93) and F mean 1.07 (SD = 0.83). Overall rating of the interview was 8.30 (SD = 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD = 0.52), F 0.58 (SD = 0.93) and A 1.42 (SD = 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients' illness narratives. We argue for further refinements of the CFI.

The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice

While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.

Update on the Cultural Formulation Interview

This article reviews the clinical and research literature on the Cultural Formulation Interview (CFI) since its publication in DSM-5. The CFI is an interview protocol designed to be used by clinicians in any setting to gather essential data to produce a cultural formulation. The CFI aims to improve culturally sensitive diagnosis and treatment by focusing clinical attention on the patient's perspective and social context. Preliminary evidence indicates that the CFI can improve clinical communication by enhancing clinician-patient rapport, allowing the clinician to obtain new, cultural data in a relatively short period, eliciting patients' perspectives on what caused their symptoms, and helping patients to become aware of their problems in more insightful ways. With practice, the CFI takes approximately 20 minutes to complete. The CFI has been evaluated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally has been found to be clinically acceptable and useful in these varied settings. Clinicians receiving as little as one hour of training on the CFI improved their ability to work with culturally diverse patients. The CFI may be more difficult to conduct with patients who have severe symptoms, including acute psychosis, suicidal behavior, aggression, and cognitive impairment. The CFI provides a simple way to begin the process of cultural assessment, and its systematic use can foster a reflective stance and promote systemic thinking in routine clinical practice about the patient's life and experience.