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Silvius L, Antezana J KV, Ghane S. Symptom vs context: lessons learned from a large-scale implementation of the Cultural Formulation Interview. Front Psychiatry 2024; 15:1410865. [PMID: 39296860 PMCID: PMC11408998 DOI: 10.3389/fpsyt.2024.1410865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/05/2024] [Indexed: 09/21/2024] Open
Abstract
Mental health services in multicultural societies require culturally sensitive approaches to reduce health disparities. The Cultural Formulation Interview (CFI) is thought to enhance shared decision making and to facilitate culturally and contextually informed treatment. There is, however, little known regarding its implementability in large-scale psychiatric services. The current paper reports on (a) efforts to implement the CFI in a large organization for mental health services in the Netherlands, and (b) two studies that evaluated this implementation process and identified barriers to CFI adoption in clinical practice. Implementation of the CFI was facilitated by developing an online course, an advanced training of "team coaches", (digital) resources, and integrating the CFI questions into the intake format. A preliminary evaluation revealed that the CFI was administered in only 13.2% of all intakes across the entire organization, with minimal utilization of training resources. Study 1 aimed to investigate how the CFI was perceived by clinicians and stakeholders. A survey of 150 clinicians found a great lack of familiarity with the CFI and its purpose. While 67% reported partial CFI use, 50% saw no added value, and 61% deemed it relevant only for ethnic minorities. Study 2 examined which patient and clinician variables were associated with adequate CFI use (i.e., correct documentation of the CFI information in initial intake reports). The sample consisted of 112 intakes of patients conducted by ten clinicians. Regression analysis showed a significant association between clinicians' cultural competences and adequate CFI use, meaning that more culturally competent clinicians tended to generate better cultural assessments using the CFI. In addition, the CFI information was documented more adequately among patients who were unemployed at the time of assessment. In conclusion, implementation of the CFI requires a fundamental rethinking of the entire intake assessment, shifting it from a symptom-oriented approach towards a context- and person-centered one. Future trainings may benefit from embedding the CFI within a broader cultural competency training, rather than solely focusing on the CFI, which is currently the common practice.
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Affiliation(s)
- Linda Silvius
- Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands
| | | | - Samrad Ghane
- Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands
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Brand AM, Groen SPN, Destoop N, Jongsma HE, Ghane S, Sabbe BGC, van Velsen H, van Houten K, Becan Ö, Al Alyan D, Braakman MH. The effect of the cultural formulation interview on therapeutic working alliance: a study protocol. Front Psychiatry 2024; 15:1322356. [PMID: 38501082 PMCID: PMC10945007 DOI: 10.3389/fpsyt.2024.1322356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/14/2024] [Indexed: 03/20/2024] Open
Abstract
Background The Cultural Formulation Interview (CFI) is designed to improve understanding of patients' mental health care needs. The lack of empirical evidence on the impact and effectiveness of CFI use in clarifying people's perspectives, experiences, context, and identity, and in preventing cultural misunderstandings between migrant patients and clinicians, inspired this study. The objective is to examine the effect of the CFI on the strength of therapeutic working alliances, and the potential mediating or moderating role of perceived empathy. Materials and methods A multicenter randomized controlled trial will be conducted, involving migrant patients, their confidants, and clinicians. The CFI will be administered in the intervention group, but not in the control group. Validated questionnaires will be used to assess therapeutic working alliances and perceived empathy. T-tests and linear regression analyses will be conducted to investigate between-group differences and possible mediating or moderating effects. Results This study will indicate whether or not the CFI strengthens the therapeutic working alliance between patients and clinicians, as moderated and/or mediated by perceived empathy. Discussion Research on the effect and impact of using the CFI in mental health care for migrant patients is important to clarify whether its use strengthens the therapeutic working alliance with clinicians. This can lead to a reduction in cultural misunderstandings and improve mental health care for migrant patients. The results may also be important for the implementation of the CFI as a standard of care. Ethics and dissemination This research protocol was tailored to the needs of patients in collaboration with experts by experience. It was approved by the Ethical Review Board of the Tilburg Law School and registered in the Clinical Trials Register under number NCT05788315. Positive results may stimulate further implementation of the CFI in clinical practice, and contribute to improving the impact of the CFI on the therapeutic working alliances.
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Affiliation(s)
- Alma M Brand
- Tilburg Law School, Tilburg University, Tilburg, Netherlands
| | - Simon P N Groen
- De Evenaar, Center for Transcultural Psychiatry, GGZ Drenthe, Beilen, Netherlands
| | - Nathalie Destoop
- Mobile 2B Team SPITT and Culture-sensitive Care POZAH, Psychiatric Hospital Sint-Alexius Grimbergen, Brussels, Belgium
| | - Hannah E Jongsma
- Center for Transcultural Psychiatry Veldzicht, Balkbrug, Netherlands
- University Center of Psychiatry, University Medical Center Groningen (UMCG), Groningen, Netherlands
| | | | - Bernard G C Sabbe
- Faculty of Medicine and Health Sciences, Collaborative Antwerp Psychiatric Research Institute, University of Antwerpen, Antwerpen, Belgium
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Claus L, Schouler-Ocak M, Braakman MH, Sabbe B, Van Beuren G, van den Ameele S. Unlocking asylum seekers' voices: protocol of a mixed-method clinical study on the use of the cultural formulation interview with asylum seekers in Belgium. Front Psychiatry 2023; 14:1156803. [PMID: 37215655 PMCID: PMC10192900 DOI: 10.3389/fpsyt.2023.1156803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023] Open
Abstract
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.
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Affiliation(s)
- Lukas Claus
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Universiteit Antwerpen (UA), Antwerp, Belgium
- Department of Psychiatry, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Meryam Schouler-Ocak
- Department of Psychiatry and Psychotherapy, Psychiatric University Clinic of Charité at St. Hedwig Hospital, Berlin, Germany
| | - Mario H. Braakman
- Department of Psychiatric Residency Training, Pro Persona Mental Health, Wolfheze, Netherlands
- Department of Criminal Law, Tilburg Law School, Tilburg University, Tilburg, Netherlands
| | - Bernard Sabbe
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Universiteit Antwerpen (UA), Antwerp, Belgium
| | - Godfried Van Beuren
- Management Culturally Sensitive Care, St. Alexius Psychiatric Hospital, Grimbergen, Belgium
| | - Seline van den Ameele
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Universiteit Antwerpen (UA), Antwerp, Belgium
- Department of Psychiatry, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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Jones-Lavallée A, Bernard G, Taing J, Leanza Y. The State of Current Knowledge on the Cultural Formulation Interview: A Scoping Review. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2022. [DOI: 10.1007/s10862-022-10009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Lindberg LG, Carlsson J, Kristiansen M, Skammeritz S, Johansen KS. The Cultural Formulation Interview-Generating distance or alliance? A qualitative study of practice changes in Danish mental healthcare. Transcult Psychiatry 2022; 59:740-755. [PMID: 35331059 DOI: 10.1177/13634615211065617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Laura Glahder Lindberg
- Competence Centre for Transcultural Psychiatry, Mental Health Center Ballerup, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark.,Department of Public Health, University of Copenhagen, Denmark
| | - Jessica Carlsson
- Competence Centre for Transcultural Psychiatry, Mental Health Center Ballerup, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Kristiansen
- Department of Public Health, University of Copenhagen, Denmark Center for Healthy Aging, University of Copenhagen, Denmark
| | - Signe Skammeritz
- Competence Centre for Transcultural Psychiatry, Mental Health Center Ballerup, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Katrine Schepelern Johansen
- Competence Centre for Dual Diagnosis, Mental Health Center Sct Hans, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
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Lindberg LG, Johansen KS, Kristiansen M, Skammeritz S, Carlsson J. Negotiating Engagement, Worthiness of Care and Cultural Identities Through Intersubjective Recognition: Migrant Patient Perspectives on the Cultural Formulation Interview in Danish Mental Healthcare. Cult Med Psychiatry 2021; 45:629-654. [PMID: 33170411 DOI: 10.1007/s11013-020-09694-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Laura Glahder Lindberg
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Maglevænget 21, 2750, Ballerup, Denmark. .,Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Katrine Schepelern Johansen
- Competence Centre for Dual Diagnosis, Mental Health Centre Sct. Hans, Mental Health Services of the Capital Region of Denmark, Roskilde, Denmark
| | - Maria Kristiansen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Signe Skammeritz
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Maglevænget 21, 2750, Ballerup, Denmark
| | - Jessica Carlsson
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Maglevænget 21, 2750, Ballerup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kizilhan JI, Wenzel T. Positive psychotherapy in the treatment of traumatised Yezidi survivors of sexualised violence and genocide. Int Rev Psychiatry 2020; 32:594-605. [PMID: 33016807 DOI: 10.1080/09540261.2020.1809356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
So far, the psychotherapeutic treatment of patients with trauma spectrum disorders has most commonly been based on a disease model in which the normal reaction to trauma results in negative emotions, cognitions and behaviour which, in turn, cause a pathological state of mind or disorder. Here, trauma is associated with distress. This model focuses on identification, classification and treatment of the pathological and maladaptive modulations of the stress response that lead to psychological and social suffering and disability. In contrast to that, recent models in the Psychotherapy of the sequels of extreme life experiences, such as Positive Psychotherapy, have rather focussed on the building of competence, resilience and posttraumatic growth. In this article we summarise our experience in treating Yazidi women for their complex psychological traumata resulting from their experience of ISIS terror. We will use a short summary of published secondary data and reviews and use case examples from our work as primary data to discuss possible individual and collective resources that can help them to recover and to maintain a positive perspective on their person and the world, in spite of their terrible traumatic experiences. Original models of Positive Psychology already paid considerable attention to strength and resilience. The new approach of 'second wave' Positive Psychology expands on this, suggesting that negative emotions as well cultural factors must also be integrated. This approach appears to be particularly helpful in the treatment of this group of Yazidi women. Likewise, it seems to be promising when treating similar groups of people who survived extreme terror and were continuously exposed to genocidal environments.
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Affiliation(s)
- Jan Ilhan Kizilhan
- Institute for Psychotherapy and Psychotraumtology, University of Duhok, Duhok, Iraq.,Institute of Transcultural Health Science Cooperative State University Baden-Württemberg, Villingen-Schwenningen, Germany
| | - Thomas Wenzel
- World Psychiatric Association Scientific Section on Psychological Aspect of Persecution and Torture and OEGBA, University of Vienna, Vienna, Austria
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