Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment

The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI—i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient—could prove helpful in alleviating patients’ suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.

Full-Scale Case Conceptualization Practice

This chapter demonstrates the eight-step full-scale case conceptualization strategy using two case vignettes. The chapter summarizes the following eight-step strategy: Step 1: Specify presenting problem and precipitants; Step 2: Identify maladaptive pattern; Step 3: Identify predisposing factors and perpetuants; Step 4: Specify a cultural formulation; Step 5: Specify the client’s relevant protective factors and strengths; Step 6: Specify treatment goals; Step 7: Specify treatment interventions; and Step 8: Specify obstacles, challenges, and facilitators. The readers will formulate the cases through the full-scale case conceptualization worksheet and then will write a full-scale case conceptualization narrative for each case. Exemplar responses for each of the two case vignettes are provided.

Impact on routine psychiatric diagnostic practice from implementing the DSM-5 Cultural Formulation Interview: A pragmatic RCT in Sweden

BackgroundCulture and social context affect the expression and interpretation of symptoms of distress, raising challenges for transcultural psychiatric diagnostics. This increases the risk that mental disorders among migrants and ethnic minorities are undetected, diagnosed late or misdiagnosed. We investigated whether adding a culturally sensitive tool, the DSM-5 core Cultural Formulation Interview (CFI), to routine diagnostic procedures impacts the psychiatric diagnostic process. MethodWe compared the outcome of a diagnostic procedure that included the CFI with routine diagnostic procedures used at Swedish psychiatric clinics. New patients (n=256) admitted to a psychiatric outpatient clinic were randomized to a control (n=122) or CFI-enhanced diagnostic procedure (n=134) group. An intention-to-treat analysis was conducted and the prevalence ratio and corresponding 95% confidence intervals (CI) were calculated across arms for depressive and anxiety disorder diagnoses, multiple diagnoses, and delayed diagnosis. ResultsThe prevalence ratio (PR) of a depressive disorder diagnosis across arms was 1.21 (95% CI=0.83-1.75), 33.6% of intervention-arm participants vs. 27.9% of controls. The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI=0.91-2.86). The prevalence ratio of receiving multiple diagnoses was higher for the CFI group among non-native speaking patients, and lower to a statistically significant degree among native Swedish speakers (PR=.39, 95% CI=0.18-0.82). ConclusionsThe results suggest that the implementation of the DSM-5 CFI in routine psychiatric diagnostic practice may facilitate identification of symptoms of certain psychiatric disorders among non-native speaking patients in a migration context. Trial registrationISRCTN36661, 29/07/2019. The trial was retrospectively registered.

A Review and Clinical Practice Guideline for Health Professionals Working With Indigenous and Culturally and Linguistically Diverse (CALD) Populations During COVID-19

Background: As the rates of infection and mortality from COVID-19 have been higher in minority groups, the communication of health information in a way that is understood and accepted is of particular importance.Aims: To provide health professionals with a clinical practice guideline for clear and culturally sensitive communication of health information about COVID-19 to people of Indigenous and culturally and linguistically diverse (CALD) backgrounds.Assessment of Guideline Options: The authors conducted a review of the literature on health communication, and the guidelines were developed with particular reference to the SPIKES protocol of “breaking bad news” in oncology and the use of the DSM-5 Cultural Formulation Interview (CFI).Actionable Recommendations: The guideline combines two approaches, the Cultural Formulation Interview, developed for DSM-5, and the SPIKES protocol used for delivering “bad news” in oncology. The combined CFI-SPIKES protocol is a six-step clinical practice guideline that includes the following: (1) Set up (S) the interview; (2) Determine how the patient perceives the problem (P) using the Cultural Formulation Interview (CFI) to elicit the patient's cultural perception of the problem; (3) Obtain an invitation (I) from the patient to receive a diagnosis; (4) Provide the patient knowledge (K) of diagnosis in a non-technical way; (5) Address the patient's emotional reaction (E) to diagnosis; and (6) Provide the patient a summary (S) of healthcare and treatment.Conclusions and Relevance: This article presents guidelines for assessing the cultural dimensions of patients' understanding of COVID-19 and delivering diagnostic and treatment recommendations in ways that are culturally safe and responsive, such as: (a) suspending the clinician's own cultural biases to understand the explanatory models and cultural values of their CALD or Indigenous patients; (b) encouraging the use of interpreters or cultural brokers to ensure that that the message is delivered in a way that the patient can understand; and (c) encouraging CALD or Indigenous patient to take an active part in the solution and treatment adherence, to minimize transmission of COVID-19 in CALD and Indigenous communities.

Интервью культуральной оценки в диагностике состояния психического здоровья: результаты международного полевого испытания в Нидерландах

Введение. Вопросам, связанным с культуральной обусловленностью психики, уделяется всё больше внимания в связи с ростом культурного разнообразия общества в результате усилившихся в последние десятилетия потоков миграции во всем мире. В рамках редакционной доработки представлений о взаимосвязи культуры и психики в DSM-Ⅴэкспертная секция по кросс-культуральным вопросам разработала Интервью культуральной оценки (Cultural Formulation Interview ‒ CFI) из 16 вопросов, предложенное использовать в диагностике состояния психического здоровья. Дополнением к DSM-Ⅴслужит подготовленное недавно коллективом авторов второе издание Клинического руководства по культурной психиатрии. Руководство подготовлено в соответствии с принципами, изложенными в DSM-V, где предлагается подробная инструкция по применению интервью по проблемам, связанным с культурной средой при постановке диагноза (Clinical Manual of Cultural Psychiatry, 2015). Цель: определение восприятия CFI пациентами (n=30) и клиницистами (n=11) по параметрам: удобство и простота в выполнении, приемлемость и клиническая полезность. Исследование проводилось как часть масштабного международного клинического полевого испытания в пяти странах. Более ранние исследования обнаружили, что этническое многообразие психиатрической популяции в Нидерландах имеет тенденцию ограничивать коммуникацию в сфере психического здоровья и уменьшать точность постановки психиатрического диагноза. Полуструктурированные интервью разработаны в Нидерландах с целью определения культуральных проблем при психодиагностической оценке. Результаты. 11 нидерландских клиницистов после обучения применению CFI в рамках структурированной программы провели 30 интервью в двух группах: 1-я группа ‒ пациенты иностранного происхождения, 2-я группа ‒ пациенты-коренные жители Нидерландов. Клиницисты и пациенты использовали количественные и качественные опросники до и после назначения CFI. Пациенты и клиницисты положительно оценили удобство, простоту выполнения и приемлемость CFI. Пациенты более позитивно оценили клиническую полезность CFI по сравнению с клиницистами. Применение клиницистами CFI не приводило к изменению диагнозов психических расстройств в связи с идентичной оценкой уровня психического здоровья в разных институтах Нидерландов. Таким образом, CFI является удобным и простым в выполнении, приемлемым и потенциально клинически полезным инструментом в психиатрической практике. Его использование расширяет возможности стандартного психиатрического обследования пациентов с диагностическими и коммуникативными проблемами.