An Introduction to the Cultural Formulation Interview

Culture shapes every aspect of patient care in psychiatry, influencing when, where, how, and to whom patients narrate their experiences of illness and distress, the patterning of symptoms, and the models clinicians use to interpret and understand symptoms in terms of psychiatric diagnoses. Culture also shapes patients’ perceptions of care, including what types of treatment are acceptable and for how long. Even when patients and clinicians share similar ethnic or linguistic backgrounds, culture affects care through other influences on identity, such as those attributable to gender, age, class, race, occupation, sexual orientation, and religion/spirituality. Because cultural contexts and expectations frame the clinical encounter for every patient, and not just those from underserved minority groups, cultural formulation is an essential component of any comprehensive psychiatric assessment.

Acknowledging that illnesses occur in cultural and social contexts, DSM-5 includes two questionnaires to aid clinicians with cultural formulation. The first questionnaire, known as the core Cultural Formulation Interview (CFI), contains instructions for clinicians in a left column and 16 questions with probes for direct patient interviewing in a right column, similar in format to other standardized questionnaires such as the Structured Clinical Interview for DSM-IV. In addition, there is an informant Cultural Formulation Interview (I-CFI) for clinicians to use with close associates of patients, such as family, friends, caregivers, and others who can provide collateral information. Finally, DSM-5 includes 12 supplementary modules to the core CFI, which provide additional questions to investigate a topic in greater depth or include topics of additional concern (e.g., phase in the life cycle for certain populations, such as children and adolescents or older adults).

This set of interviews is known collectively as the CFIs, and they greatly expand the clinician’s tool kit so that attention to cultural issues remains integral throughout the process of diagnostic and treatment planning. APA has made all of these interviews available online for free on its Web site (www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures) in recognition of the growing interest in clinician cultural formulation. This article reviews the development of the core CFI and discusses its contents in detail so that clinicians can develop a working understanding of the theoretical foundations common to all of the interviews.

Development of the CFI

Outline for Cultural Formulation

The core CFI, I-CFI, and all 12 supplementary modules were developed by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) based on reviews of the scientific literature since the publication of the Outline for Cultural Formulation (OCF) in 1994. The development process is discussed elsewhere in greater depth (1) but is summarized here for background. The OCF was an early attempt at standardizing cultural formulation that first appeared in DSM-IV. The OCF was developed as a conceptual framework—a summary of the topics that could be included in a cultural formulation during a mental health evaluation to improve diagnostic accuracy and patient engagement in treatment planning. These topics were organized in four OCF domains: cultural identity of the individual, cultural explanations of the individual’s illness, cultural factors related to psychosocial environment and levels of functioning, and cultural elements of the relationship between the individual and the clinician. Information from these domains influencing diagnosis and treatment was summarized and synthesized in a fifth section to provide an overall formulation.

For the past 20 years, the OCF has been a widely taught cultural assessment tool in mental health care. Members of the DCCIS included clinicians and researchers from around the world who attempted to implement the OCF in diverse organizational and practice settings, attesting to the significant international interest in cross-cultural patient formulation (2). Although a substantial scholarship has emerged since the 1970s to propose different cultural interviews based on varying lengths that clinicians can use with patients, there have been few attempts to analyze their similarities and differences. The DCCIS therefore provided an institutional mechanism for international experts to come together regularly and advance a consensus approach that synthesized common topics covered under various interviews and proposed revisions to shortcomings discovered in the OCF. A revised version of the OCF was also included in DSM-5 (1).

A Definition of Culture

A major advance of the DCCIS was the development of a single definition for culture that can be used for clinically relevant practice. This definition is found in DSM-5, and the CFI operationalizes this definition in the form of questions to patients as follows:

This definition captures the multiple, vibrant sources of meaning that we all draw upon to comprehend our experiences throughout life, including those of illness and suffering. Such meanings can be inherited and acquired, derived through symbolic systems such as language and creed, inherent to patterns of social organization such as families and legal systems, and ever-changing as our priorities and identities shift according to our development along the lifespan. A fundamental tenet of this definition is that culture exists in the ties that bind people to social groups. Instead of reducing cultural identity to a single demographic trait such as language, race, or ethnicity without considering its effects on patients (3, 4), the CFI encourages clinicians to inquire about the various sources of meaning that affect how all stakeholders in health care make sense of illnesses and decisions about care.

Developing Guidelines for Implementing the CFI

Aside from this consensus definition of culture, members of the DCCIS also worked on developing guidelines for clinicians on how to implement the CFI. The first step was to prepare literature reviews on extant cultural assessments available to clinicians. The literature reviews followed certain assumptions (1). First, the DCCIS recommended that clinicians responsible for diagnosis and treatment planning should complete the CFI. This stance differs from the notion that other members of a clinical team, such as interpreters or cultural brokers, should conduct cultural assessments because these staff members, who undoubtedly perform valuable functions, may not be called for each patient or may not be available in all settings. Moreover, the intent of the CFI is to elicit the patient’s own perspective on his or her illness experience, which is very useful information for all clinicians to obtain.

Second, the DCCIS sought to harmonize the CFI with the OCF by identifying problems in either the OCF’s content or its implementation in clinical settings. DCCIS members conducting the literature reviews assessed areas for possible revision in written drafts that were circulated and discussed in committee meetings. For the core CFI, the literature reviews culminated in an initial draft of the interview that was later tested among clinicians, patients, and (in some settings) members of the patient’s social network as part of the DSM-5 field trials. In this manner, the CFI revision process adhered to the general revision process for DSM-5, in which expert individuals conducted comprehensive literature reviews to pinpoint areas for revision, proposed recommendations in committee, and then field tested recommendations with human participants. The CFI field trial was conducted in mental health clinics in Canada, India, Kenya, the Netherlands, Peru, and the United States. Resource constraints prevented the DCCIS from field testing the I-CFI and the supplementary modules, and these interviews were developed in DCCIS subcommittees (2, 5).

An example of an area identified for revision since the OCF publication was the need for instructions for clinicians on the logistics of conducting a cultural formulation. The OCF included an outline of key topics that would be helpful to assess, but there were no actual questions that well-intentioned clinicians could use, no guidelines on when a cultural formulation would be useful, and no explanation for cultural concepts that may have been unfamiliar to clinicians (6). In response to this lack of implementation instructions, the core CFI now consists of 16 questions with instructions for clinicians. These instructions orient clinicians on the type of information that is sought for each question. The DCCIS also recommended that clinicians from any professional background (e.g., psychiatrists, psychologists, social workers, counselors, therapists, or nurses) begin every standard clinical assessment with the core CFI. Peer providers, employment counselors, and other recovery specialists are also encouraged to use the CFI to conduct a cultural formulation as part of their work. The interview has been designed for use with patients with any diagnosis and in all settings, including inpatient units, outpatient clinics, rehabilitation centers, emergency rooms, and transitional settings such as intensive outpatient programs. At the same time, the DCCIS also acknowledged that certain constraints may limit use of the full CFI and that providers can implement questions according to their needs. Experience in teaching services suggests that the CFI can be used to bridge patient and provider understanding even in acute clinical settings, such as psychiatric emergency rooms, in which safety is the top priority. Clinicians may choose to use some CFI questions in the first encounter and other questions in subsequent encounters based on the patient’s clinical stability. This comprehensive approach affirms that all patients and clinicians possess cultural backgrounds that affect clinical care; that cultural considerations are not restricted only to racial, ethnic, or linguistic minorities; and that the institutional context of service delivery influences the clinical encounter.

Furthermore, the DCCIS has recognized five specific situations in which cultural factors would be especially important for evaluation. First, there may be difficulty in diagnostic assessment owing to significant differences in the cultural, religious, or socioeconomic backgrounds of the clinician and the individual. The underlying principle describing this situation is to use the CFI when a clinician is unfamiliar with the patient’s culture, regardless of similarities or differences in background or identity. Second, there may be uncertainty about the fit between culturally distinctive symptoms and diagnostic criteria. In this situation, there may be uncertainty between the diagnostic criteria and any of the patient’s symptoms, not only those that either the clinician or the patient might consider culturally distinctive. Third, there may be difficulty in judging illness severity or impairment. Here, the clinician may not understand the level of severity indicated by the person’s symptoms (e.g., whether the patient is describing a delusion or a strongly held view common in the person’s culture) or how the patient’s symptoms represent a clinically significant impairment in academic, occupational, or social functioning. Fourth, there may be disagreement between the individual and clinician on the course of care. Patients and clinicians may not agree on the length and types of treatments most needed for the patient’s symptoms. Finally, there may be limited engagement in and adherence to treatment by the individual. Once treatment has started, patients may demonstrate variations in full adherence to recommended treatment modalities. The CFI responds to these situations by asking patients about their views of health, illness, and treatment through key questions.

The questions in the core CFI represented another topic of active deliberation within the DCCIS. The OCF has been criticized on the grounds that some topics in its four domains may overlap too much and lead to redundant information or replicate content elicited from the social history in routine clinical assessments (7, 8). DSM-IV also did not specify when the OCF should be used: Should clinicians obtain all information in each of the four domains or pick and choose as necessary? Is there a recommended order? Should the cultural formulation be completed in the same session as the diagnostic interview or later? These questions have remained an active area of research on the CFI. To provide clarity, the DCCIS reorganized the OCF domains so that the CFI questions can be used at the beginning of every clinical assessment. First, clinicians should obtain all information in each of the four CFI sections when possible. Analyses of transcripts from the DSM-5 CFI field trial indicate that clinicians in busy outpatient services could obtain all information in each of the CFI’s four sections while completing the standard clinical assessment within 1 hour (2). Second, the CFI questions have been written in a particular order to maintain clinical rapport throughout the interview. For example, because the OCF lists cultural identity first, it implied that clinicians should assess this domain first. Some members of the DCCIS raised concerns that patients may not understand why clinicians are asking about their cultural identities without first inquiring into the problems being presented or establishing trust in a clinical environment. For this reason, the CFI includes questions on patient cultural identity after general questions on how patients define their problem and perceive its causes, context, and sources of support. Although the CFI questions are in the recommended order, the order in which clinicians ask them may vary depending on how the interview evolves in practice. Finally, circumstances will dictate whether the cultural formulation can be completed in the same session as the diagnostic interview. DSM-5 states that the CFI can be used in a variety of situations. For new patients, the CFI can precede the standard diagnostic assessment. However, the five specific situations outlined in DSM-5 indicate that a diagnostic assessment may have already occurred. In these situations, the CFI can help clinicians conduct an additional cultural formulation that may come later than the diagnostic assessment but nonetheless imparts critical and clarifying information.

All of the CFI interviews can be used to obtain cultural information in a patient-centered way. The introduction to the core CFI that clinicians can say to patients to frame the interview emphasizes that “there are no right or wrong answers.” This acknowledgment underscores the patient’s right to construct a narrative about the illness experience in recognition that this narrative may differ from the clinician’s biomedical understanding of the disease process (9). Clinicians who are skilled in the CFI do not overlook or disregard patient-clinician differences; rather, they use cultural content to co-construct a narrative about illness with patients and negotiate a treatment plan that all parties can find feasible, acceptable, and useful (10).

Content of the Core CFI

Having discussed the development process of the CFI, this article now turns to its content. The core CFI comprises four sections. The first section, known as the “Cultural Definition of the Problem,” includes the first three questions. Question 1 is “What brings you here today?” Although this question may not appear to have a specific cultural focus, its open-ended nature is intended to elicit the patient’s view of core problems and concerns. The intent is to begin the clinical encounter with the issues that matter most to patients rather than to prioritize biomedical signs and symptoms (11). A prompt is included if the individual gives few details or only mentions biomedical terms: “People often understand their problems in their own way, which may be similar to or different from how doctors describe the problem. How would you describe your problem?” This prompt empowers patients to share their experiences of distress in narrative form without concern for medical accuracy. Question 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?”) situates the patient’s description of the problem within the social network, recognizing that culture exists in the ties between people and shapes how information is processed and communicated differently based on audience, including patients and clinicians (12). Question 3 (“What troubles you most about your problem?”) obtains perceptions of illness severity in order to discuss impairments from the patient’s perspective.

Questions 4–10 compose the second section, “Cultural Perceptions of Cause, Context, and Support.” Question 4 (“Why do you think this is happening to you? What do you think are the causes of your [PROBLEM]?”) explores the patient’s meaning of illness. This information can be useful for treatment planning. For example, patients who perceive their illness to be caused by difficult interpersonal relationships may not want to try medication, whereas patients who believe that their illness is biologically inherited may be more receptive to pharmacotherapy (13). The “[PROBLEM]” placeholder is designed for clinicians to use the patient’s terms and phrases throughout the rest of the interview in order to build rapport and linguistically enter the patient’s life world (14). Language matching is one explicit communication strategy that the CFI promotes to reduce cultural misunderstandings between patients and clinicians. Patients may use biomedical vocabulary such as “depression” or common vernacular terms such as “the baby blues” in discussing their experiences, and clinicians can use such terms in the placeholder. A prompt can help patients consider a range of causes for more complete answers: “Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or many other causes.” The prompt normalizes the possibility that differences may exist between patient and clinician perceptions of illness causes without prioritizing any single meaning. Question 5 (“What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?”) asks the patient to consider what members of the social network understand as the cause of illness. Questions throughout the CFI that ask the patient to think about topics from the perspectives of close associates are concrete ways in which the CFI operationalizes the DSM-5 definition of culture as transmitted among groups. The CFI assesses all four OCF domains. Questions 1–5 address many of the elements of a cultural assessment mentioned in OCF domain B, titled “Cultural Conceptualizations of Distress” in DSM-5, including “cultural constructs that influence how the individual experiences, understands, and communicates his or her symptoms or problems to others” (p. 750). Other elements of OCF domain B are tapped in later CFI questions on coping (Question 11) and help seeking (Questions 12–15).

Domain C of the OCF, “Psychosocial Stressors and Cultural Features of Vulnerability and Resilience,” is addressed in CFI Questions 6 and 7 on supports and stressors. Question 6 asks “Are there any kinds of support that make your [PROBLEM] better, such as support from family, friends, or others?,” whereas Question 7 asks “Are there any kinds of stresses that make your [PROBLEM] worse, such as difficulties with money, or family problems?” Both of these questions can help patients and clinicians appreciate how other individuals and situations may improve or worsen the problem in expanding the focus of the interview to include the social contexts of illness (15).

Questions 8–10 tackle domain A of the OCF, “Cultural Identity of the Individual.” They serve as a transition to how the patient’s cultural identity relates to the problem being presented. Question 8 begins with an introduction to activate patients toward considering diverse sources of cultural identity: “Sometimes, aspects of people’s background or identity can make their [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, or your faith or religion.” This introduction provides examples of identities that may be salient for the patient. Question 8 (“For you, what are the most important aspects of your background or identity?”) then poses a question directly to the patient to encourage a patient-centered approach of eliciting and understanding this important cultural information. This method releases clinicians from the burden of guessing the patient’s identity, which has sometimes characterized previous and now outmoded models of cultural competence (4). Instead, the CFI opts for a patient-centered approach to culturally competent care. Question 9 (“Are there any aspects of your background or identity that make a difference to your [PROBLEM]?”) asks patients to assess the relationship between cultural identity and the problem presented. This question can prevent clinicians from assuming that a particular form of care is needed for a certain social group (e.g., a racial or ethnic community) without first considering its relevance to individual patient care. Question 10 (“Are there any aspects of your background or identity that are causing other concerns or difficulties for you?”) moves from the clinical setting to the patient’s social context as another way of situating the illness within general life experiences. Problems with migration, immigration status, gender roles, or intergenerational conflict may be mentioned as possible answers and can provide valuable information on the extent to which resources (2) are available to patients as clinicians devise treatment plans.

Questions 11–13 compose the third CFI section, “Cultural Factors Affecting Self-Coping and Past Help-Seeking.” The objective of this section is to evaluate which interventions—at the individual, community, or clinical levels—have improved or worsened the patient’s condition. Question 11 (“Sometimes people have various ways of dealing with problems like [PROBLEM]. What have you done on your own to cope with your [PROBLEM]?”) clarifies the individual’s forms of self-coping. Question 12 moves beyond the individual to address help seeking at the community level, either with or without receipt of biomedical services: “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]?” A prompt for this question illuminates which types of help may be mobilized for current treatment planning: “What types of help or treatment were most useful? Not useful?” Question 13 can elucidate barriers in accessing care: “Has anything prevented you from getting the help you need?” Another prompt follows to help clinicians consider the range of resources for the current illness episode: “For example, money, work or family commitments, stigma or discrimination, or lack of services that understand your language or background?”

The final three questions constitute the fourth and final CFI section, “Cultural Factors Affecting Current Help Seeking.” Question 14 transitions from the past to the present illness episode: “Now let’s talk some more about the help you need. What kinds of help do you think would be most useful to you at this time for your [PROBLEM]?” The goal of this question is to elicit the patient’s perceived needs and expectations of help. Question 15 reviews treatment preferences according to members of the patient’s social network: “Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?” These questions complete the assessment of patients’ cultural views of help seeking and self-care described in domain B of the OCF.

Question 16 begins with an open-ended statement before a direct question to the patient in contemplating perceived similarities and differences in the current patient-clinician relationship: “Sometimes doctors and patients misunderstand each other because they come from different backgrounds 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?” The goal of this question is to anticipate concerns and resolve potential conflicts while putting domain D of the OCF into practice. Under this fourth domain, “Cultural Features of the Relationship Between the Individual and the Clinician,” the CFI suggested:

The goal of this question is to help patients identify differences that could cause difficulties in communicating with providers. A strong therapeutic alliance is crucial to diagnostic accuracy and treatment engagement, and this question can signal to patients that providers are willing to establish trust and safety. After this question, clinicians can proceed to the standard assessment, having begun the encounter by prioritizing the patient’s point of view.

Mission of the CFI

It is important to note that the CFI is 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 becomes at least as important as the signs and symptoms of disease identified by the clinician. The mission of the CFI is in fact to expand what counts as data in a clinical encounter, encouraging the clinician—and the patient, who is empowered to recount his or her experience more fully—to attend to the experience of illness and the life world. 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. 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 that 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—can facilitate a process of shared decision making, including negotiating and clarifying the subsequent concrete steps and decisions for both partners in the session.

Conclusions

The CFI is a state-of-the-art tool for clinicians to use in conducting cultural formulations with patients. Calls for patient-centered care and health equity have increasingly led to the development of standards for cultural and linguistic competence for clinicians and service organizations (16). The CFI fulfills these functions by ascertaining the cultural meanings of health, illness, and treatment from the patient’s perspective. The CFI also restores the patient’s voice to the clinical encounter, offering a complementary perspective to diagnostic interviews that may otherwise elevate symptom checklists over intimate experiences of suffering and care.