Cultural Formulation Interview

Dorie J. Gilbert and Katarzyna Olcoń

ABSTRACT

Research indicates that practitioners’ cultural biases are a barrier to effective cross-cultural

assessment; thus, social work practitioners must demonstrate the ability to appraise a client’s

cultural context in assessing and treating mental health concerns. The Cultural Formulation

Interview (CFI) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides

practitioners with a standardized cultural assessment method for use in mental health practice.

The CFI addresses culture from four domains: 1) cultural definition of the problem, 2) cultural

perception of cause, context, and support, 3) cultural factors affecting self-coping and past help-

seeking; and 4) cultural factors affecting current help-seeking. This chapter provides a

comprehensive overview of the CFI with a particular focus on racial/ethnic disparities in mental

health care and assessment, and discusses additional considerations for cross-cultural assessment

as well as implications for social work education and practice.

Keywords: Cultural Formulation Interview; mental health assessment; DSM-5; cultural

competence
 INTRODUCTION

Understanding the impact of a client’s culture and context in mental health assessment is

essential to effective social work practice. Introduced with the 5th revision of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5) in 2013, the Cultural Formulation Interview

[CFI] is a type of assessment that allows service providers to learn about the impact of culture

and context on a patient’s clinical presentation and care. As a standardized and manualized tool

designed to capture cultural factors in mental health assessment, the CFI has been shown to

increase culturally competent assessment practices (Mills, Xiao, Wolitzky-Taylor, Lim & Lu,

2017) and improve medical communication among patients and clinicians mostly by increasing

rapport and eliciting patients’ narratives (Aggarwal, DeSilva, Nicasio, Bioler, & Lewis-

Fernandez, 2015).

The DSM-5 Cultural Issues Subgroup led the development of the CFI, which is an

improvement on the Outline for Cultural Formulation (OCF) found in DSM-4 (American

Psychiatric Association [APA], 2000). The DSM-5 defines culture in the following way:

Culture is therefore a multifactorial set of overlapping systems made up of many

components beyond race and ethnicity, including not only the characteristics mentioned

above but also gender identity, sexual orientation, and even generational cohort and

occupational group. The views and practices associated with the confluence of these

cultural characteristics affect how all participants in the health care process—patients and

their relatives, as well as clinicians, administrators, and policy makers—understand

illness and engage in care (APA, 2013b, p. 749).

The CFI is useful for all facets of multicultural practice. For example, military culture includes

patterns of beliefs, language, and cultural practices that impact use of healthcare services and

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health practices. In speaking about the need for practitioners to understand and be trained in

military cultural competence, Meyer, Writer, and Brim (2016, p. 1) call attention to the words of

Sir William Osler (1849-1919): “it is much more important to know what sort of a patient has a

disease than what sort of disease a patient has.” Misunderstanding the worldview of a client can

lead to ethical dilemmas and misdiagnosis. The Islamic perspective of mental health, for

instance, is dramatically different from the Judeo-Christian nosology of mental health, and

practitioners must be able to elicit the client’s understanding of the presenting problem related to

their cultural and religious identity (Rasool, 2015). Social class and classism can also create

barriers to effective assessment. Sue and Sue (2016) note that mental health professionals are

often unaware of additional stressors likely to confront clients who lack financial resources and

the manner in which these stressors shape affect their client, and therapists who come from

middle-to-upper-class backgrounds may find it difficult to relate to circumstances and hardships

affecting clients who live in poverty.

Thus, the overall intent of the CFI is to guide practitioners in asking the client “What

should we know about you that contextualizes you and understands you from a cultural lens?”

The CFI also addresses idea that the importance of cultural context extends to practitioners, who

possess particular expectations or interpretations based on their personal experiences (Lewis-

Fernandez, 2015). Sue and Sue (2016, p. 294) note that “this view (i.e., that contextual and

therapist factors are also important in therapy outcome)” moves the field forward in recognizing

the complexities involved in mental health assessment and treatment across a broad range of

cultural differences.

Although definitions of culture, multiculturalism, and diversity are extensive and

inclusive of many identities and experiences defined by race, gender, class, disability, sexual

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orientation, religious and spiritual beliefs, and other factors (e.g. NASW, 2015; Sue & Sue,

2016), most of the literature on the CFI is focused on cultural assessment related to race,

ethnicity or national identity (Jackson, Williams, & VanderWeele, 2016; Williams, McGuire,

Wang, & Miranda, 2008). Thus, this chapter focuses predominantly on historically excluded

racial ethnic groups due to the well-documented mental health disparities and evidence of

misdiagnosis and poor assessment related to racial/ethnic and nationality factors (Meyer & Zane,

2013; Smith & Trimble, 2016). Many racial/ethnic groups hold concepts of what constitutes

mental health, mental illness, and adjustment that are different from mainstream American

culture (Sue & Sue, 2016), and the changing U.S. demographics underscore the need to give

particular attention to how the CFI can be useful for improving cross-cultural assessment with

historically excluded racial and ethnic groups.

U.S. Demographics and Race, Ethnicity, and Nationality

Non-Hispanic Whites in the U.S are individuals with ethnic ancestry linked to various

European heritages, such as English, Italian, or Irish (Waters, 2001) or other persons who have

easily assimilated through phenotype and identify as Whites. This group generally benefits from

societal power and privilege based a long history of economic, political and social advantages

(Feagin & Feagin, 2011). Due to the social construction of race in the U.S. society, racial or

ethnic minority individuals have been historically oppressed and marginalized; they suffered

discrimination in the past and remain targets of disproportionate negative outcomes due to the

structural inequity embedded in the U.S. social fabric. The disadvantages experienced by racial

and ethnic minority groups occur across many domains in life (i.e., employment, housing,

education) and include disparities in mental health care and mental health assessment.

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 By the year 2060, historically excluded racial and ethnic groups in the United States will

represent 56 percent of the population (U.S. Census Bureau, 2017). As of 2017, non-Hispanic

Whites make up 63 percent of the U.S.; Hispanics, 17 percent; Blacks, 13 percent; Asians, 5

percent, and multiracial Americans, 2.4 percent. The population of Americans younger than 5

years old was 49.9 non-White, and multiracial Americans are the fastest growing group,

followed by Asians and Hispanics. Also, the number of immigrants, especially immigrant youth,

arriving in the United States has increased dramatically over the past two decades (Passel &

Cohn, 2008), with individuals from Mexico, India, China and the Philippines comprising the

majority of this population (Zong & Batalova, 2017). It is estimated that by 2050, immigrant

children and adolescents will make up one-third of all youth in the United States (Passel, 2011).

As defined by the DSM-5 Cultural Issues Subgroup, race is a socially constructed

category of identity that divides people into groups based on superficial physical traits attributed

to hypothetical intrinsic, biological characteristics (Aggarwal et al., 2015). Although race has no

genetic basis, it has many social and political implications and is crucial for understanding

people’s experiences and opportunities (Shih, Bonam, Sanchez, & Peck, 2007). Ethnicity is a

culturally constructed group identity that defines communities rooted in history, geography,

language, religion, or other shared characteristics (Aggarwal et al., 2015). Dein (2006) defined

ethnicity as another way of thinking about human diversity that implies: “shared origins or social

background, shared culture and traditions that are distinctive, maintained between generations,

and lead to a sense of identity and group; and as common language or religious tradition (p. 69).

Both race and ethnicity are socially constructed and those within any group vary widely

in how and whether they identify with aspects ascribed to the group. Some research argues that

the emphasis should be placed more on the psychosocial stressors that adversely affect members

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of any societally oppressed racial/ethnic group, given evidence that racism can exacerbate many

psychiatric disorders and contributes to poor mental health outcomes (APA, 2013b). In addition,

race, ethnicity, and culture are intertwined; however, race is societally assigned based on

physical appearance; culture is learned and practiced based on beliefs, values, and life symbols.

Although individuals identifying with a particular race or ethnicity may have different cultural

orientations, persons of a particular race or ethnicity often share cultural systems associated with

their specific racial/ethnic group. A lack of sensitivity to diverse cultural orientations, whether

related to or differentiated from race or ethnicity, can lead to practitioner bias and mental health

misdiagnosis.

Mental Health Care Disparities

In 2001, then-Surgeon General David Satcher issued his report, Race. Culture, and

Ethnicity and Mental Health (DHHS, 2001), which documented that racial and ethnic minority

groups were underserved and ineffectively served by mental health professionals; and as a result,

they experience mental health care disparities. The Institute of Medicine (IOM) defines disparity

as a difference in health care quality not due to differences in health care needs or preferences of

the patient (Smedley, Stith, & Nelson, 2003), which are rooted in various causes, such as unequal

access to good providers, differences in insurance coverage, or discrimination by health

professionals in the clinical encounter. Using a national data set (the Medical Expenditure Panel

Survey, or MEPS), Black-White and Hispanic-White disparities in rates of any mental health

care use worsened from 2000–01 to 2003–04 (Cook, McGuire & Zuvekas, 2009). Another

national sample of English-speaking people from 1990-2003 indicated overall rates of treatment

for psychiatric disorders increased, but not for Blacks who were only 50 percent as likely as

Whites to receive psychiatric treatment for diseases of similar severity (Kessler et al., 2005).

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Hispanics are more frequently undertreated than are Whites, and based on a series of studies,

only 36 percent of Hispanics with depression received care, compared to 60 percent of Whites

(Dingfelder, 2005).

These studies along with other extensive literature document marked disparities by race

and ethnicity that exists in the treatment of depression, anxiety disorders, and severe mental

illness. Racial/ethnic minorities are reported to have poorer access to care, receive lower quality

service, and have higher attrition rates, compared to Whites, regardless of diagnosis (Sue & Sue,

2016; Williams, McGuire, Wang, & Miranda, 2008). Compared to Whites, members of racial

and ethnic minority groups in the U.S. are less likely to have access to mental health services,

less likely to use community mental health services, more likely to use inpatient hospitalization

and emergency rooms, and more likely to receive lower quality care, even when they do have

access to care (Williams et al., 2008). In their review of the literature on community samples,

Williams, Neighbors, and Jackson (2003) concluded that discrimination and racism are

“generally associated with poor health status” and that the “association was the strongest in the

case of mental health” compared to physical health (p. 202).

Meyer and Zane (2013) examined 102 clients who received mental health treatment from

outpatient mental health clinics to investigate whether culturally related elements involving race

and ethnicity were important to clients, and whether they were related to client satisfaction and

perceived treatment outcomes. Ethnic minority clients noted that issues regarding race and

ethnicity were important more so than did White clients. When these elements were considered

important but were not included in their care, clients were less satisfied with treatment. This

indicates how attention to racial and ethnic factors and their relationship to client’s culture are

critical factors in mental health disparities.

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 Recently, Smith and Trimble (2016) offered a comprehensive analysis of whether

disparities in mental health services have improved since the U.S. Surgeon General' Stacher’s

warning in 2001 that racial and ethnic minority populations were underserved. The authors

presented a series of meta-analyses drawing on data from more than 4.7 million clients in 130

research studies. The meta-analyses revealed that racial and ethnic discrepancies have decreased

somewhat, but are still substantial (Smith & Trimble, 2016). African-Americans are 21 percent

less likely than Whites to use mental health services, and Hispanics and Latinos are 25 percent

less likely. Asian Americans are by far the racial group that was most likely to underutilize

mental health services given their percentage in the population; they are 51 percent less likely to

take advantage of mental health services than their White counterparts.

Jackson and colleagues (2016) argued that examining multiple forms of marginalization

through the intersectional lens can illuminate how outcomes are patterned for social groups that

are marginalized across multiple axes of social inequality, such as social economic status or

access to healthcare. However, notwithstanding reports that socioeconomic status or differences

in health insurance access account for disparities, Smith and Trimble (2016) reported from their

meta-analyses that race is an equally independent predictor of mental health utilization but also

argued that “we need a better understanding of how labels are used in the context of

unscrambling the deep meaning of culture…" (Clay, 2016, p. 18). Understanding the cultural

context of illness experience is essential for effective diagnostic assessment and clinical

management” (APA, 2013b, p. 749), and is needed to reduce bias in mental health assessment.

Bias in Mental Health Assessment

According to Snowden (2003), the dominant cultural standards (i.e., White, middle-class,

heterosexual, male) have tended to result in more diagnoses of mental disorders and pathology

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among those who are outside the dominant culture than in it, and racial biases can affect

diagnostic assessment (APA, 2013b). The use of traditional Eurocentric assessment strategies for

racial/ethnic groups who experience life differently from a predominately Euro-American society

remains controversial (Gielen, Draguns & Fish, 2008). While universal psychotherapeutic

assessments and measurement tools have been found effective among majority White

populations, the lack of developed assessment approaches for historically excluded or

marginalized groups essentially voids the true universality of these many accepted standard

assessment approaches. As most mental health assessment approaches are taught and practiced

from a Westernized perspective, practitioners may lack cultural knowledge of values, traditions,

and belief systems that are essential to assess and treat historically excluded and marginalized

racial and ethnic group members (Epstein et al., 2012; Liu, Ivey & Pickett, 2007). This results in

misdiagnoses and differential assessment outcomes and mental health care disparities for non-

majority racial and ethnic group clients. The Cultural Formulation Interview is an important step

to assist practitioners in culturally sensitive diagnosis.

CULTURAL FORMULATION INTERVIEW

Prior to the introduction of the DSM-5 Cultural Formulation Interview, the DSM-4

(APA, 2000) used a general guideline of potential questions and areas to be addressed by

clinicians referred to as the Outline for Cultural Formulation (OCF). Given the outline’s

unstructured format and lack of clear instructions, clinicians reported being unsure of how to use

it, and they were confused about whether or not it could be used in addition to a standard clinical

assessment (Aggarwal et al., 2015). There were also some discussions as to which settings were

appropriate for the outline’s use (Aggarwal et al., 2015).

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 The OCF was generally used inconsistently or underutilized in routine community

settings, although some literature supports that when employed appropriately, it produced

culturally-congruent assessment (Fortuna, Porche & Alegria, 2009). In a special issue of

Transcultural Psychiatry – “Cultural Formulation” there are several studies that show OCF’s

usefulness in working with culturally diverse clients. For example, the OCF was used in

assessment of PTSD in a predominantly Latino sample, and majority of the clinicians found it

useful in helping them consider culture within a diagnostic formulation (Fortuna et al., 2009).

Groen (2009) described a case study of a Somali patient in Netherlands. Guided by OCF, the

psychiatrist encouraged the patient to discuss his cultural identity and ethnic roots, which greatly

improved the patient’s engagement in treatment and improvement over time. Another case study

explored the culture-bound syndromes - ataque de nervios (attack of nerves) in a Columbian

woman living in the U.S. (Lizardi, Oquendo, & Graver, 2009). The authors advocated for

creating a specific diagnostic category for ataque in the new version of the DSM in addition to its

presence in the glossary of culture-bound syndromes. Rosso and Bäärnhielm (2012) examined

the contribution of the cultural formulation to understanding migrants in a Swedish psychiatric

outpatient unit. They suggested that DSM-5 should incorporate more focus on the experiences

related to migration and acculturation.

Despite these examples, it is generally agreed that OCF lacked concrete methods for

collecting the required cultural information, which, some scholars believe, minimized its use

among clinicians (Mezzich, Caracci, Fabrega, & Kirmayer, 2009). The OCF was also found to

be confusing to refugee patients in Netherlands as they had difficulty defining their own culture

or providing explanations of illness (Rohlof, Knipscheer, & Kleber, 2009). Finally, based on 75

psychiatric evaluations in Madrid that involved the use of OCF, Caballero (2009) concluded:

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 …the procedures for implementing the CF should avoid setting up cultural assessment as

opposed to the biological formulations currently dominant in psychiatry, as the CF is

sometimes perceived, but rather should facilitate the integration of the Cultural

Formulation into everyday mental health practice. (p. 521)

In response to this criticism, the DSM-5 Cultural Issues Subgroup aimed to create a tool that

would be feasible, acceptable, and clinically useful in daily practice (DeSilva, Aggarwal, &

Lewis-Fernández, 2015). In addition, supplementary modules were developed for specific

populations including children, elderly, immigrants and refugees. Finally, CFI has been tested on

300 patients and 75 clinicians in 6 countries: Canada, India, Kenya, the Netherlands, Peru, and

the United States (DeSilva, Aggarwal, & Lewis-Fernández, 2015).

As opposed to OCF, which has been described as vague and difficult for formulating

specific questions, the CFI includes a set of 14 standardized questions, probes and question

explanations, which provide a systematic guidance and instructions for clinicians through the

assessment (Aggarwal, et al., 2015). To promote its use by clinicians with their patients and to

achieve broad dissemination, CFI can be freely downloaded from the American Psychiatric

Association (APA) website and reproduced without permission from the research team and

practitioners.

The CFI is a result of long-term efforts of cultural psychiatrists and medical

anthropologists under the leadership of Dr. Roberto Lewis-Fernández, Professor of Clinical

Psychiatry at Columbia College of Physicians and Surgeons and Director of the New York State

(NYS) Center of Excellence for Cultural Competence. As emphasized by Lewis-Fernández and

Díaz (2002), the cultural formulation model is essential as it “supplements the biopsychosocial

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approach by highlighting the effect of culture on the patient’s symptomatology, explanatory

models of illness, help-seeking preferences, and outcome expectations” (p. 273).

CFI has also shown great progress in the conceptualization of culture, patient-centered

approach to cultural assessment, and the relationship building between the patient and the

clinician. CFI was designed to avoid stereotyping by moving toward a process-oriented, dynamic

definition of culture as opposed to promoting the myth of fixed, stable cultural traits of racial and

ethnic group members.

In addition, once the clinician learns the patient’s preferred term for his or her illness,

“the clinician substitutes the patient’s term for every question that includes the word ‘problem.’”

(Aggarwal et al., 2015, p. 3). “Speaking the language of the patient” (American Psychiatric

Association, 2013b, p. 759) allows a clinician to build a better rapport and to elicit patient’s own

narrative of illness. This is facilitated by the open-ended nature of the CFI questions.

Some examples of questions on CFI are: “Sometimes people have different ways of

describing their problem to their family, friends, or others in their community. How would you

describe your problem to them?”, “Are there any aspects of your background or identity that

make a difference to your [problem]?” and “What kinds of help do you think would be most

useful to you at this time for your [problem]?”. All of the CFI questions are placed in one of the

four domains: 1) Cultural Definition of the Problem, 2) Cultural Perception of Cause, Context,

and Support, 3) Cultural Factors affecting self-copying and past help seeking; and 4) Cultural

factors affecting current help seeking. Together, the CFI questions and domains aim to help the

clinician obtain useful clinical information, prevent clinical misdiagnosis (e.g. spiritual

explanation may be misunderstood as psychosis), and to improve patient engagement and

therapeutic efficacy. “The CF model supplements the biopsychosocial approach by highlighting

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the effect of culture on the patient’s symptomatology, explanatory models of illness, help-

seeking preferences, and outcome expectations” (Lewis-Fernández & Díaz, 2002, p. 273).

Culture provides interpretive frameworks that shape the experience and expression of the

symptoms, signs and behaviors that are criteria for diagnosis considering three cultural concepts:

 cultural syndrome: cluster of co-occurring symptoms found in a specific cultural group,

community or context (e.g. ataque de nervios)

 cultural idiom of distress: linguistic term, phrase or way of talking about suffering

specific to a cultural group

 cultural explanation or perceived cause: explanatory model among a cultural group for

causes of symptoms, illness or distress

Four Domains of the CFI

The CFI includes four domains: 1) Cultural definition of the problem, 2) Cultural

perception of cause, context, and support, 3) Cultural factors affecting self-copying and past help

seeking and 4) Cultural factors affecting current help seeking. Table 1 list the CFI questions

specific to each category.

Cultural Definition of the Problem. The first three questions on the Cultural

Formulation Interview fall under the category of Cultural Definition of the Problem. The aim of

this domain is to learn about the individual’s perspective of his/her core problems and key

concerns. The clinician is supposed to focus on the individual’s own way of understanding the

problem (Hoyos, 2017). Question ‘What brings you here today? (APA, 2013a, p. 1) is supposed

to facilitate obtaining this information. Additionally, clinicians are supposed to ask the individual

how he/she frames the problem for members of his/her social network. Finally, through the

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question ‘What troubles you most about your problem?’ (APA, 2013a, p. 1) clinician can learn

about the aspects of the problem that matter most to the individual (Hoyos, 2017).

Cultural Perception of Cause, Context, and Support. This domain is designed to allow

the clinicians learn about patient’s understanding of the causes of his/her problem, stressors and

supports in their environment and the role of cultural identity. Specifically, the questions ‘Why

do you think this is happening to you? What do you think are the causes of your [problem]?’

(APA, 2013a, p. 1) indicates the meaning of the condition for the individual, which may be

relevant for clinical care (Hoyos, 2017). It is also essential to elicit the views of members of the

individual’s social network as they may be different from the perspective of the individual. In

order to assess patient’s supports, clinicians should ask about the patient’s life context, resources,

social supports, and resilience (‘Are there any kinds of support that make your [problem] better,

such as support from family, friends, or others? (APA, 2013a, p. 2). A clinician also needs to

learn about patient’s stressors including relationship problems, difficulties at work or school, or

discrimination (Are there any kinds of stresses that make your [problem] worse, such as

difficulties with money, or family problems? (APA, 2013a, p. 2). The final questions in this

domain are related to the patient’s identity. Patients are to be encouraged to reflect on the most

salient elements of their cultural identity, whether any aspect of their identity is making the

problem better or worse, and if their identity is causing other concerns or difficulties for them.

Cultural Factors Affecting Self-Coping and Past Help Seeking. This domain is

intended to elicit information about patient’s self-coping, past help seeking and barriers to help

seeking. Clinicians should first clarify the meaning of self-coping for the problem: “Sometimes

people have various ways of dealing with problems like [problem]. What have you done on your

own to cope with your [problem]? (APA, 2013a, p. 2). Next, providers are to elicit various

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sources of help (e.g., medical care, mental health treatment, support groups, work-based

counseling, folk healing, religious or spiritual counseling, other forms of traditional or alternative

healing). Clinicians should also clarify the individual’s experience and regard for previous help

(Hoyos, 2017). Finally, it is crucial to assess any barriers that patients may be experiencing in

help seeking, access to care, and problems engaging in previous treatment: ‘Has anything

prevented you from getting the help you need?’ (APA, 2013a, p. 3). The probes that CFI

provides for this question may be especially helpful: “What got in the way?” and “For example,

money, work or family commitments, stigma or discrimination, or lack of services that

understand your language or background?’ (p. 3).

Cultural Factors Affecting Current Help Seeking. Finally, in this domain, clinicians

can assess patient’s preferences for treatment: ‘What kinds of help do you think would be most

useful to you at this time for your [problem]? (APA, 2013a, p. 3). Clinicians should focus on

individual’s current perceived needs and expectations of help (Hoyos, 2017) and can use CFI

probes such as “What other kinds of help would be useful to you at this time?” (p. 3). The final

area of assessment is the clinician-patient relationship. Clinicians should pay attention to

“possible concerns about the clinic or the clinician-patient relationship, including perceived

racism, language barriers, or cultural differences that may undermine goodwill, communication,

or care delivery” (Hoyos, 2017, p. 18).

Overall, CFI takes on an anthropological point of view and moves away from the cultural

competence – cultural traits approach. In addition, practitioners are encouraged to use the CFI

with any patient not just members of racial and ethnic groups.

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Table 1. Four Domains of the Cultural Formulation Interview [CFI]

Domain of Cultural Questions

Formulation
Interview

Cultural definition of 1. What brings you here today?

the problem 2. Sometimes people have different ways of describing their problem to
their family, friends, or others in their community. How would you
describe your problem to them?
3. What troubles you most about your problem?

Cultural perception of 1. Why do you think this is happening to you? What do you think are the
cause, context, and causes of your [PROBLEM]?
support 2. What do others in your family, your friends, or others in your com-
munity think is causing your [PROBLEM]?
3. Are there any kinds of support that make your [PROBLEM] better, such
as support from family, friends, or others?
4. Are there any kinds of stresses that make your [PROBLEM] worse,
such as difficulties with money, or family problems?
5. For you, what are the most important aspects of your background or
identity?
6. Are there any aspects of your background or identity that make a
difference to your [PROBLEM]?
7. Are there any aspects of your background or identity that are causing
other concerns or difficulties for you?

Cultural factors 1. Sometimes people have various ways of dealing with problems like
affecting self-copying [PROBLEM]. What have you done on your own to cope with your
and past help seeking [PROBLEM]?
2. 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]?
3. Has anything prevented you from getting the help you need?

Cultural factors 1. What kinds of help do you think would be most useful to you at this
affecting current help time for your [PROBLEM]?
seeking 2. Are there other kinds of help that your family, friends, or other people
have suggested would be helpful for you now?
3. Have you been concerned about this and is there anything that we can
do to provide you with the care you need?

Note: Adopted from the Cultural Formulation Interview [CFI] by the American Psychiatric
Association (2013)

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Evaluation of Cultural Formulation Interview

The Cultural Formulation Interview is a significant step forward and represents a strong

commitment to culturally grounded assessment compared to previous DSM versions (Aggarwal

et al., 2015). Several studies have evaluated the CFI in various settings. For example, Paralikar,

Sarmukaddam, Patil, Nulkar, and Weiss (2015) examined the feasibility, acceptability, and utility

of CFI in India, in an urban outpatient psychiatry clinic serving lower middle-class patients. The

authors found that the patients, relatives, and clinicians rated the CFI positively. Interestingly,

CFI received higher clinicians’ and patients’ ratings in the absence of relatives. The CFI was also

evaluated in a Mexican outpatient clinic (Ramírez Stege & Yarris, 2017). The study showed that

CFI can increase trust between patients and providers and is especially relevant to eliciting

information about patients’ social networks and support. Ramírez Stege & Yarris (2017)

reported, however, that questions about “background or identity” were frequently misunderstood

by both patients as well as the providers as relevant only to rural or indigenous communities.

Several other barriers to the implementation of CFI have been identified. Since its

introduction in 2013, practitioners have reported issues with using the CFI, similar to the

criticism of the OCF or DSM-4 version. Criticism of the CFI include: 1) lacks conceptual

relevance between intervention and problem, 2) drifts from the format, 3) is repetitive, 4)

severity of patient illness, 5) lack of clinician motivation/buy-in, and 6) time needed to

implement the assessment (Aggarwal, Nicasio, DeSilva, Boiler, & Lewis-Fernández, 2013).

Specifically, clinicians found that some parts of the Interview are repetitive and many used parts

of the CFI rather than the whole questionnaire. Moreover, some clinicians found CFI unfeasible

for patients with psychotic disorders or developmental disorders (Aggarwal, et al., 2013). CFI is

thus at risk of being underutilized similarly to the DSM-4 cultural assessment, which as Lewis-

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Fernandez (2009) pointed out was “underutilized in actual clinical practice, likely due to limited

dissemination efforts towards practicing clinicians and because of the time required for its

implementation (p. 379).

Other concerns are related to the narrow focus of Cultural Concepts of Distress in DSM-

V. The following are included in the Glossary of Cultural Concepts of Distress:

 Ataque de nervios - intense emotional upset (Latino)

 Dhat syndrome – anxiety, fatigue, weakness, weight loss, impotence (South Asia)

 Khyal cap – panic attack (Cambodians)

 Kufungisisa – range of psychopathology (Zimbabwe)

 Maladi moun – range of medical and psychiatric disorders (Haiti)

 Nervios – state of vulnerability and stressful life experiences (Latino)

 Shenjing shuairuo – weakness, worry, insomnia (China)

 Susto – distress and misfortune (Latino)

 Taijin kyofusho – anxiety and avoidance of interpersonal situations (Japan)

While the DSM-5 is meant for a global audience, within the U.S., practitioners may find the

Glossary of limited relevance. There is not enough attention to the cultural concepts of distress

among the marginalized populations within the U.S. For African-descent populations, the

Glossary provides examples of cultural concepts of distress only from other countries (i.e.,

Zimbabwe and Haiti). There are no concepts of distress specific to the African American culture

mentioned. For example, Black/African Americans have a reluctance to discuss mental illness

among family and friends and, in some cases, the term “crazy” is associated with depression or

anxiety (Williams, 2011). Also, generational or historical trauma (Duran, Duran, Yellow Horse

Brave Heart, & Yellow Horse-Davis, 1998), which describes the intergenerational trauma

18
experienced by Native Americans, is not mentioned; neither is racism-based trauma

(Karumanchery, 2003; DeGruy, 2005) or responses to micro-aggressions. These are critical

issues given the well-established research documenting the association of experiences of racism

and ethnic identity with individuals’ mental health and well-being (Aymer, 2010; Pieterse,

Neville, Todd, & Carter, 2012). The lack of focus on the impact of societal oppressions on

sources of mental health concerns results in practitioners looking only for individual level

cultural explanations of distress while the effects of social inequities remain masked (Olcoń &

Gulbas, 2018; Viruell-Fuentes, Miranda, & Abdulrahim, 2012). Practitioner must also be able to

assess poor mental health resulting from structural oppression and the way in which it shapes the

experiences of the increasing numbers of historically marginalized racial/ethnic and increasing

numbers of immigrant groups.

There is ample room for future research to further evaluate and continue improving the

Cultural Formulation Interview, and in turn, to provide higher quality of mental health services

to racial and ethnic minority clients and other underserved groups. The DSM-5 Cultural Issues

Subgroup responsible for the development of CFI posed several important questions that future

research needs to answer:

To what extent does a culturally oriented interview change important aspects of care,

including diagnosis, treatment planning, and patient satisfaction and adherence? Can

patient engagement be enhanced through personalized forms of clinical negotiation and

exchange of clinician-patient perspectives through the CFI? Does a brief standardized

interview such as the core CFI actually help clinicians assess culture and context?

(Lewis-Fernández et al., 2014, p. 147)

19
Future research should also look at the value of using CFI with other groups, including veterans,

people with disabilities, members of religious groups and others.

IMPLICATIONS FOR SOCIAL WORK EDUCATION AND PRACTICE

There is clearly a role for social work in the utility and use of the Cultural Formulation

Interview. For example, databases searches for “social work” and “cultural formulation” yielded

less than five results in total and most were not directly relevant. The only social work

publication was by Panos and Panos (2000), and the authors discussed a model for a culture-

sensitive assessment of patients in health care settings. In this article, published in Social Work

in Health Care, the authors provided case examples from Navajo, Laotian, and Cambodian

cultures. Increased use of the DSM-5 Cultural Formulation Interview by social work mental

health practitioners is important. As more social work practitioners incorporate the CFI in

practice and engage in research and publishing about its use, they can contribute to the discourse

and increase the understanding about the efficacy of this tool. Further social work education

must ensure that students are familiar with the DSM-5 Cultural Formulation Interview. We

recommend, however, that CFI be strengthened by an anti-racist framework which allows for a

more comprehensive picture of an individual from racial/ethnic minority background. As Maiter

(2009) explained:

…when the central element of our work with members of diverse ethnoracial groups is

culture, we may then tend to inadvertently exclude the effects of race and racism in the

lives of people of color while at the same time clients themselves will not bring up issues

relating to race. (p. 269)

20
 Given the well-documented issues of biased mental health assessment and mental health

care disparities, social work mental health practitioners should be on the forefront of culturally

grounded assessment efforts based on the profession’s commitment to effectively engaging

diversity and difference (CSWE, 2015; NASW, 2015). Rosenberg, Almeida, and Macdonald

(2012) noted that success of culturally-appropriate assessment for social workers can be

attributed in part to the practitioner’s awareness and ability to forgo, when necessary, a

Eurocentric orientation to assessment and adopt the client’s value system. The authors discussed

how practitioners can act as co-creators of assessment when working with culturally diverse

clients. Moreover, it is important to note that practitioners must first be aware of their own

cultural orientation - whether it is Eurocentric or otherwise - in order to understand fully the

starting point of the cross-cultural assessment process. The growing heterogeneity of the U.S.

will undoubtedly require all social work practitioners of a myriad of backgrounds to engage in

cross-cultural practice and assessment. The more diverse our society, the more likely a client and

practitioner will not share the same cultural orientation, value or understanding of mental health

concepts.

With all the challenges related to cross-cultural assessment, some scholars argue that the

cultural competence model commonly used in social work practice with diverse clients does not

sufficiently address the complexity and the necessary components of working across cultural

differences (Ben-Ari & Strier, 2010; Dean, 2001; Pon, 2009). Another promising approach of

preparing social workers for culturally relevant practice and assessment is the cultural humility

model (Fisher-Borne, Cain, & Martin, 2015; Hook, 2014; Johnson & Munch, 2009; Ortega &

Coulborn, 2011). Tervalon and Murray-García (1998) introduced the Cultural Humility Model to

address public healthcare disparities and physician training outcomes in multicultural education.

21
They defined cultural humility as “a lifelong commitment to self-evaluation and critique, to

redressing the power imbalances in the physician-patient dynamic, and to developing mutually

beneficial and non-paternalistic partnerships with communities on behalf of individuals and

defined populations” (p. 123). Tervalon & Murray-García (1998) emphasized that cultural

humility is a lifelong process of learning that includes building knowledge about a specific

population a practitioner is serving, but they also warn against stereotyping or making

assumptions about a client based on his or her cultural background. Commenting on a study that

found that poor and minority patients received less information about their conditions, less

positive speech, and less talk overall from physicians than did other patients, Tervalon and

Murray-García (1998) called for medical care that places the patient in the center of the

professional relationship. They elaborated that practitioners need to learn from clients, who are

the expert on their lives, and respect their values and perspectives. Finally, cultural humility, as

originally proposed, needs to include community-based care, advocacy, and institutional

accountability. Tervalon and Murray-García (1998) explained that physicians need to be trained

in community settings to “learn to identify, believe in, and build on the assets and adaptive

strengths of communities and their often disenfranchised members” (p. 122). In addition to

individual self-refection and self-critique, institutions should engage in the same process by

asking question about their true commitment to effectively serving diverse populations (Tervalon

& Murray-García, 1998). To summarize, the model includes three major components: 1) self-

refection and life-long learning, 2) institutional and individual accountability, and 3) mitigation

of systemic power imbalances.

Other scholars suggest that helping professions should move away from cultural

interpretations of their patients’ behaviors and instead focus on social inequality and look inward

22
into individual and institutional causes of inequalities and dominance (Giroux, 2000). The

concept of culture is frequently too narrowly understood and does not include patient’s life

context and life opportunities, which are always shaped by power dynamics and social structures.

Cultural interpretations as implemented in practice settings may therefore not only be ineffective,

but can potentially be harmful to culturally diverse clients. For example, Metzl and Hansen

(2014) rejected the notion of cultural competency and advocate for “structural competency” as a

way to deal with stigma and inequality in medical encounters. Likewise, Holmes (2012) added

that “it is not the culture of the patient, but rather the structure and culture of biomedicine that

form the primary barriers to effective multicultural health care” (p. 873). Both the “structural

competency” and “cultural humility” are models that have been aimed at improving cross-

cultural practice in the medical field, and they certainly have relevance to the social work

profession.

CONCLUSION

This chapter provided a general overview of the current state of mental health care

disparities and an in-depth description of the DSM-5 Cultural Formulation Interview, which is a

working tool for inclusion of culture in four assessment domains. The long-term impact of this

assessment tool remains to be seen. While there is evidence of some limited improvements in

racial/ethnic mental health care (Smith & Trimble, 2016), serious misdiagnoses continue to exist,

and factors such as race and ethnicity still matter in terms of mental health diagnosis. The

creation of new questionnaires and assessment tools is important, but there is a real need to link

assessment to culturally grounded mental health care.

At the same time that the DSM-5 Cultural Formulation Interview is being touted for its

potential to positively impact cross-cultural assessment strategies, other bodies of literature point

23
to the limitation of a focus on culture as opposed to a greater understanding and emphasis on

societal structures of oppression that create and exacerbate mental health concerns for a growing

number of historically oppressed racial/ethnic groups and newly marginalized immigrant

populations. Both foci are important, and the mere intensity of the multicultural population shift

calls for greatly increased attention to understanding the role of race, ethnicity, and culture in

counseling and the unique counseling needs of marginalized groups in the U.S. which may

receive inaccurate and culturally biased assessments, diagnosis, and interventions. The

demographic and social shifts will undoubtedly require well-honed cultural awareness and

complex assessment skills for mental health practitioners.

24
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Further Reading

Aggarwal, N. K., Desilva, R., Nicasio, A. V., Boiler, M., & Lewis-Fernandez, R. (2015). Does

the Cultural Formulation Interview for the fifth revision of the diagnostic and statistical

manual of mental disorders (DSM-5) affect medical communication? A qualitative

exploratory study from the New York site. Ethnicity & Health, 20(1), 1-28.

doi:http://dx.doi.org/10.1080/13557858.2013.857762

Aggarwal, N. K., Nicasio, A. V., DeSilva, R., Boiler, M., & Lewis-Fernández, R. (2013).

Barriers to implementing the DSM-5 Cultural Formulation Interview: A qualitative study.

Culture, Medicine and Psychiatry, 37(3), 505–533.

Lewis-Fernández, R., Aggarwal, N. K., Bäärnhielm, S., Rohlof, H., Kirmayer, L. J., Weiss, M.

G., . . . Lu, F. (2014). Culture and psychiatric evaluation: Operationalizing cultural

formulation for DSM-5. Psychiatry: Interpersonal & Biological Processes, 77(2), 130-

154. doi:10.1521/psyc.2014.77.2.130

National Association of Social Workers [NASW]. (2015). Standards and indicators for cultural

competence in social work practice. Retrieved from

https://www.socialworkers.org/LinkClick.aspx?

fileticket=PonPTDEBrn4%3D&portalid=0

35
Paralikar, V. P., Sarmukaddam, S. B., Patil, K. V., Nulkar, A. D., & Weiss, M. G. (2015).

Clinical value of the cultural formulation interview in Pune, India. Indian Journal of

Psychiatry, 57(1), 59-67. doi:10.4103/0019-5545.148524

Ramírez Stege, A. M., & Yarris, K. E. (2017). Culture in la clínica: Evaluating the utility of the

Cultural Formulation Interview (CFI) in a Mexican outpatient setting. Transcultural

Psychiatry, 54(4), 466–487.

https://doi-org.ezproxy.lib.utexas.edu/10.1177/1363461517716051

Rosso, M. S., & Bäärnhielm, S. (2012). Use of the Cultural Formulation in Stockholm: A

qualitative study of mental illness experience among migrants. Transcultural Psychiatry,

49(2), 283–301. https://doi-org.ezproxy.lib.utexas.edu/10.1177/1363461512442344

Sue, D. W. & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th

Edition). New York, NY: John Wiley & Sons Inc.

The American Psychiatric Association. (2013). Cultural Formulation Interview (CFI). Retrieved

from

https://www.psychiatry.org/.../DSM/APA_DSM5_Cultural-Formulation-Interview.pdf

VIDEOS

Center of Excellent for Cultural Competence. (2014). Roberto Lewis-Fernández on the Cultural

Formulation Interview. Retrieved from https://vimeo.com/84957645

Center of Excellent for Cultural Competence. (2014). Demonstration of Cultural Formulation

Interview. Retrieved from https://www.youtube.com/watch?v=IqFrszJ6iP8

Asian American Mental Health. (2014). Culture, DSM5, and How It Will Impact Your Work.

Retrieved from https://www.youtube.com/watch?v=e9C_K37i2R4

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