Cultural Formulation Interview

The Cultural Formulation Interview (CFI) is a standardized evidence-based method for examining the impact of cultural variables on a person's illness experience. The CFI acts as a means of performing a cultural assessment during initial interviews with patients in the field of psychology. Even further, it acts as a clinical instrument designed to obtain pertinent information from the patient, and when imperative, the patient's family or partner. Derived originally from the "Outline for Cultural Formulation" (OCF) in the DSM-IV in 1974, the CFI addresses a number of difficulties reported by clinicians in their attempts to to try to elucidate more relevant information from the patients and address more specific cultural aspects of their presentations. The CFI consists of multiple parts, specifically a Core Version, an Informant Version, and twelve Supplementary Modules consisting of questions that expand on the some of the questions in the Core CFI and are only used if the clinician finds the important necessary for the individual case.

The Core Version of the CFI consists of sixteen questions and four major categories. The first category focuses on the "Cultural Definition of the Problem", encompassing broad and open-ended questions that focus on the patient's chief complaint and current psychological presentation. Clinicians use this section to ask the patient to tell their own story and describe what is known as their "illness narratives". These "illness narratives" are stories about the illness in the words of the patient and typically involve their cultural and personal perceptions of the world. In most cases, there are inclusion of people that are important to the patient, specific locations and events that led to the manifestation of the illness, any specific motives and thoughts identified by the patient, the chronological timeline usually emphasizing the past and including the present or future, as well as the emotions and behaviors associated with the illness.

The next domain refers to the "Cultural Perceptions of Cause, Context, and Support" and incorporates a very important aspect of the overall CFI, the patient's explanatory model (EM). A patient's EM is an opportunity for the clinician to focus questions that are aimed at gathering the patient's own words and descriptions of their general understanding of the problem, illness prototypes to which the patient may adhere or have been exposed, causal explanations the patient has about the illness, the course of illness as experienced by the patient, and the patient's help-seeking and treatment expectations. Although all aspects of the CFI are important, the EM is one of the most significant parts of the entire interview. Eliciting the patient's EM can help maximize treatment engagement and adherence, increase positive expectancy, help build empathy and therapeutic alliance, help identify and address catastrophic cognition, and help address the patient's experience of stigmatization. In addition to the patient's EM, this domain also involves questions about why the patient feels the problem is happening at the present moment, how their friends and family view their problem, and how the patient has coped with the problem in the past.

The third domain includes questions focused on the "Cultural factors Affecting Self-Coping and Past Help-Seeking" in regards to the patient's illness experience. The questions stress the importance of the patient's previous experiences with self-coping behaviors as well as their previous help-seeking tendencies. It is important to recognize that in many cases, individuals will often seek help outside of the medical or mental health care system before seeking help from mental health professionals. In addition, help, these questions inquire about what type of help, type of treatment, and type of medicines the patient has sought out in the past as well as from whom did they seek out these services. One major aspect of these inquires involve any barriers that the patient may have encounter while seeking help in the past, which can also include any previous experiences with the health care system and health care providers in general.

The final domain focuses on the "Cultural Factors Affecting Current Help-Seeking" and helps assist the clinicians in formulation an effective treatment plan based on the patient's current treatment expectations and preferences. The clinicians usually focus on what kind of help does the patient believe would be most useful and beneficial as well as any outside opinions that other close family or friends have considered regarding their specific illness experience. Additionally, the clinician uses these final questions to make sure to understand any previous misunderstandings or malpractices that the patient may have experienced and ultimately try to increase their therapeutic relationship by reinforcing that those issues will not happen again.

After the Core Version of the CFI, there are options to include mode questions through the use of the supplementary modules. There are twelve different modules including: Explanatory Model, Level of Functioning, Social Network, Psychosocial Stressors, Spirituality, Religion, and Moral Traditions, Cultural Identity, Coping and Help-Seeking, the Patient-Clinician Relationship, School-Aged Children and Adolescents, Older Adults, Immigrants, and Caregivers. These modules are all accessible and available at the clinicians discretion if the information would be warranted for the particular case in question. Regardless of including any other aspects of the CFI, the Core Version offers enough information by significantly focusing on how cultural variables currently influence and how they have influenced the patient and their perspective of their own illness experience. In addition, the CFI also takes into account how cultural variables, even those present in the patient and clinician relationship during the intake, can impact the quality and efficacy of the patient's care from the initial interaction throughout the entirety of the treatment process. In order to achieve cultural competency in the field of psychology, conducting Cultural Formulation Interviews with patients acts as an important first step.

1. ↑ 1.0 1.1 1.2 Kirmayer, L. J. 2016: DSM-5 Handbook on the Cultural Formulation Interview
2. ↑ Lewis-Fernández, R., & Kirmayer, L. J. (2019). Cultural concepts of distress and psychiatric disorders: Understanding symptom experience and expression in context. Transcultural Psychiatry, 56(4), 786–803. https://doi.org/10.1177/1363461519861795
3. ↑ 3.0 3.1 Kleinman A. (2017). The Illness Narratives: Suffering, Healing, and the Human Condition: [Excerpt]. *Academic medicine : journal of the Association of American Medical Colleges*, *92*(10), 1406. https://doi.org/10.1097/ACM.0000000000001864
4. ↑ 4.0 4.1 4.2 Negash, A., Ahmed, M., Medhin, G., Wondimagegn, D., Pain, C., & Araya, M. (2021). Explanatory Models for Mental Distress Among University Students in Ethiopia: A Qualitative Study. *Psychology research and behavior management*, *14*, 1901–1913. https://doi.org/10.2147/PRBM.S338319
5. ↑ Aggarwal NK, Jarvis GE, Gómez-Carrillo A, Kirmayer LJ, Lewis-Fernández R. The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice. Transcult Psychiatry. 2020 Aug;57(4):496-514. doi: 10.1177/1363461520940481. PMID:32838655.
6. ↑ 6.0 6.1 Wallin MI, Galanti MR, Nevonen L, Lewis-Fernández R, Bäärnhielm S. Impact on routine psychiatric diagnostic practice from implementing the DSM-5 cultural formulation interview: a pragmatic RCT in Sweden. BMC Psychiatry. 2022 Feb 25;22(1):149. doi:10.1186/s12888-022-03791-9. PMID: 35216555; PMCID: PMC8876131.
7. ↑ 7.0 7.1 Hoyos, A. (2017). The DSM 5 and the Cultural Formulation Interview: What it is and how to implement it. The Community Technical Assistance Center of New York. Retrieved from http://ctacny.org/sites/default/files/trainings-pdf/DSM-5%20Cultural%20Formulation%20Interview%20LF.pdf.
8. ↑ Aggarwal, N., & Lewis-Fernández, R. (2020). An Introduction to the Cultural Formulation Interview. *FOCUS*, *18*(1), 77-82. https://doi.org/10.1176/appi.focus.18103
9. ↑ 9.0 9.1 Hook, J. N. (2014). Engaging clients with cultural humility. Journal of Psychology and Christianity, 33(3), 277-280