An Introduction to the Cultural Formulation Interview

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 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.

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).