Cultural Context: The Essential Ingredient for a Whole Formulation

June 2, 2015

To determine a treatment plan, psychiatrists may consider the social and cultural context before they attempt to formulate an assessment and diagnosis of depression or another psychiatric disorder. The Cultural Formulation gives us the tools to do just that.

“Diagnose before you treat.”
“Diagnose before you treat.”
“Diagnose before you treat.”

With a nod to Professor Strunk, of Strunk and White fame, when I see patients, I often think of this teaching pearl by one of my mentors in residency. He aimed to teach succinctly, with phrases that stick in your mind. And then like Professor Strunk did, he repeated them frequently, to emphasize their importance. Those pearls come from teachers who have crystallized learned wisdom.

In attending the APA symposium on the new section on Cultural Formulation in DSM-5, my mentor’s line once again returned to my thoughts. The symposium was chaired and led by Dr Roberto Lewis-Fernández, with co-speakers Drs Neil Aggarwal, Devon Hinton, Ladson Hinton, Ravi DeSilva, and Laurence Kirmayer. Listening to them speak reminded me of the importance of truly understanding the whole picture that frames a patient’s life. We need to get a sense of the social and cultural context of a patient’s story before we attempt to formulate a diagnosis and determine a treatment plan. The Cultural Formulation gives us the tools to do just that, comprehensively. Using these tools, we can guide aspects of our interview with different kinds of patients and the people who might provide collateral information. It helps us incorporate the additional information into the usual history that we gather, which will sharpen our assessment and subsequent treatment.

The Cultural Formulation can be found in Section III of DSM-5, under Emerging Measures and Models. It begins by explaining that a clinician needs to keep 3 principles of cultural concepts in mind when taking a cultural history. The first is “cultural syndromes”: what clusters of signs and symptoms do people within a culture seem to describe together. That clustered description might indicate a disorder within that culture that people are bothered by and might want addressed and treated. The second is “cultural idioms of distress”: listening for the way a person within a certain culture describes his or her experience of a symptom or sign, almost at a metaphorical level. The third is “cultural explanations of distress”: how a person within a culture explains how he understands the distressing experience, such as why it is occurring (ie, what meaning is ascribed to the experience).

The 4 parts of the Cultural Formulation section

The core Cultural Formulation Interview (CFI) contains 16 questions that the clinician can use to understand the social and cultural context for the individual patient. Those questions can be grouped into how one defines the problem and how one explains the problem:

• Stressor or source of support

• Background or one’s identity in that context

• Ways of coping by oneself

• Past efforts and successes at seeking help

• Barriers to getting help

In planning for treatment with the interviewing clinician, these bulleted points will aid the clinician to understand the ways in which the patient seeks help: what his care preferences are and how he perceives the clinician-patient relationship.

The CFI-Informant section contains questions that the clinician can ask to get the informant’s (ie, person accompanying the patient) perspectives on the situation. The questions in the Supplementary Modules help modify the CFI or CFI-Informant versions, when interviewing either caregivers of patients or special patient populations of school-age children or adolescents, older adults, or immigrants or refugees. Finally, the Glossary is a list of terms that help cross-reference culturally based information that the clinician gathers, with diagnostic frameworks from DSM-5.

During the symposium, the speakers discussed how, through this process of interviewing a patient using the cultural formulation tools, the clinician would aim to bridge explanatory models. Imagine 2 circles, which encompass information that you have elicited from the patient. One circle contains the patient’s perceptions of the distress and explanations for it, as well as the cultural contextual information. The other circle contains the diagnostic framework in which Western psychiatrists are trained: to understand and diagnose a problem.

Assuming that you have ruled out a medical basis for symptoms and know them to be psychologically based, you might question the patient on how she understands what these symptoms mean, where they come from, how serious she perceives them to be, what has been helpful before, and what she thinks might help now. At the same time, you might frame a diagnosis of moderate depression, based on the sequence of events between her husband dying and her symptoms, her other descriptions of grief, and perhaps trouble sleeping. The aim is to “meld” the two circles into understanding this distress, perhaps building a treatment plan for moderate depression, but continuing to converse with the patient about her symptoms with language within her framework of reference.

Another important notion to keep in mind is, “What really is the “other”? We all hold a cultural framework, a way of seeing the world based on our upbringing and sociocultural background. We need to move toward a way of using the Cultural Formulation to inform our mental health work no matter what we perceive the culture of the individual patient before us to be-because it applies to all of us.

Ultimately, the use of the Cultural Formulation returns to applying patient-centered care. In doing so, we achieve 3 main outcomes: increased adherence, increased treatment satisfaction, and clearer diagnoses. For instance, the CFI can be used to explore further history with a patient who presents with symptoms that appear to indicate bipolar disorder. What if the patient offers information about war trauma as a child, that he lived in a refugee camp, and was raised by relatives when his parents were killed in the war? The clinician might better understand the patient’s mood instability to be a traumatic stress reaction and not really bipolar disorder. This affects the treatment plan, both with psychopharmacology and psychotherapy.

You may be concerned that incorporating the CFI and supplementary modules will take too much time during the patient interview. The speakers pointed out that part of getting comfortable with the CFI is to simply know its components, and then use them when you think they might be helpful. Over time, you might find yourself naturally folding it into your regular history-taking process.

Further research needs to be done in assess-ing barriers to implementation, cost-effective-ness, and perhaps thinking about how to mea-sure outcome indicators-whether qualitative or quantitative.

The implementation of the Cultural Formulation into clinical practice and mental health training will, over time, promote organizational change through increased cultural and structural competence. Using CFI tools, we will be better able to see through our patients’ eyes why illness happened, what they experience now, and what improvement they can expect. We will gain more perspective in understanding the nature of that illness and connect patients to treatment options that match their needs more closely. In essence, we will close the gap between how we as clinicians frame mental illness and how our patients give meaning to their experience of illness, thereby transforming their care through a cultural partnership.

The above is a summary of the APA Annual Meeting session, “DSM-5 Cultural Formulation Interview,” which took place on Saturday, May 17, 2015.


This article was originally posted on May 21, 2015 and has since been updated.


Dr D’Silva is a Psychiatry in Primary Care Fellow, MPH candidate; in the department of psychiatry and behavioral sciences, University of Washington, Seattle.