In the Journals

Cultural Formulation: A Special Issue of Transcultural Psychiatry

The latest issue of Transcultural Psychiatry is a special issue, entitled “Cultural Formation“. In Roberto Lewis-Fernández’s editorial introduction to the issue, he writes:

“The Outline for Cultural Formulation, developed for DSM-IV by the Group on Culture and Diagnosis of the National Institute of Mental Health, represents the most substantive cultural contribution to the DSM series. It provides instructions for conducting a cultural formulation, a systematic assessment of the patient’s cultural identity, illness representations, perceived causation, treatment expectations, cultural context of stressors and supports, and other relevant cultural factors that can be carried out with a patient from any cultural background during a mental health evaluation. … The upcoming publication of DSM-V in 2012 has provided the impetus for a thoroughgoing re-evaluation of the DSM-IV Cultural Formulation Outline. Substantial revisions are planned to the content of the Cultural Formulation, and efforts are underway to increase its visibility in DSM-V, thereby encouraging its uptake in clinical settings. … This issue of Transcultural Psychiatry greatly advances the revision of the DSM-IV Outline by addressing several of these key topics with the critical eye of the researcher who also works and thinks as a provider.” (Lewis-Fernández 2009: 379-381)


Here is a listing of the issue’s articles, along with their abstracts:

Juan E. Mezzich, Giovanni Caracci, Horacio Fabrega, Jr., and Laurence J. Kirmayer, “Cultural Formulation Guidelines

The outline for the Cultural Formulation (CF) introduced in DSM-IV does not present any method for collecting the required cultural information. The absence of specific guidelines and illustrative cases has hampered its wider use. This article offers a practical approach to preparing a Cultural Formulation as a component of culturally competent clinical care. We summarize the rationale for the four sections of the CF, describe the process of conducting culturally focused clinical interviews, and present examples of questions or lines of inquiry that can be used to collect the information needed to construct the CF. An online supplement provides case examples of cultural formulations applied to patients seen in the US.

Sofie Bäärnhielm and Marco Scarpinati Rosso, “The Cultural Formulation: A Model to Combine Nosology and Patients’ Life Context in Psychiatric Diagnostic Practice

This article discusses the experience of adapting and applying the Outline for a Cultural Formulation in DSM-IV to the Swedish context. Findings from a research project on the Cultural Formulation highlight the value of combining psychiatric nosological categorization with an understanding of patients’ cultural life context in order to increase the validity of categorization and to formulate individualized treatment plans. In clinical care practitioners need models and tools that help them take into account patients’ cultural backgrounds, needs, and resources in psychiatric diagnostic practice. We present a summary of a Swedish manual for conducting a Cultural Formulation interview. The need for further development of the Cultural Formulation is also discussed.

Lisa R. Fortuna, Michelle V. Porche, Margarita Alegría, “A Qualitative Study of Clinicians’ Use of the Cultural Formulation Model in Assessing Posttraumatic Stress Disorder

The Cultural Formulation (CF) of the Diagnostic and Statistical Manual (DSM) provides a potential framework for improving the diagnostic assessment of Posttraumatic Stress Disorder (PTSD) in culturally diverse patients. We analyzed data from the Patient-Provider Encounter Study, a multi-site study that examines the process of diagnosis and clinical decision-making during an initial clinical intake session, in order to examine use of CF for PTSD diagnosis. We find that while the CF is generally used inconsistently or underutilized in routine community settings, when employed appropriately it may assist the formulation and interpretation of traumatic experiences. We discuss the implications for improving the assessment of PTSD in the time-limited setting of the clinical intake encounter and across race/ethnicity.

Simon Groen, “Recognizing Cultural Identity in Mental Health Care: Rethinking the Cultural Formulation of a Somali Patient

Although there are many ways to produce a cultural formulation that facilitates a culturally sensitive diagnosis and treatment for asylum seekers and refugees in mental health care, it is essential to gain trust and ‘recognize’ the patient. One way to achieve this recognition is through a cultural interview, in which cultural references of the health care provider and the patient are exchanged. This paper presents an example of such a process with a Somali migrant to the Netherlands, whose passivity and inactivity puzzled the psychiatrist. Gaining his trust and recognizing his cultural roots as a member of a Somali ethnic group revealed more about his motives, concepts and attitude. This example suggests the importance of cultural identity as a way to explore the meanings of the illness and the interrelationship between the patient and health care provider. The cultural identity of the patient is a basis on which meanings can be exchanged in an ongoing way and starting points for effective treatment can be found.

Dana Lizardi, Maria A. Oquendo, and Ruth Graver, “Clinical Pitfalls in the Diagnosis of Ataque de Nervios: A Case Study

Ataque de nervios (attack of nerves) is an idiom of distress generally thought of in relation to Caribbean Hispanics. The following case study discusses the presentation of ataque de nervios in a Colombian female. This case study provides insight into a different presentation of ataque de nervios population that clinicians should be aware of in order to ensure accurate diagnosis. Ataque de nervios is a distinct syndrome that does not fully correspond with any single DSM-IV diagnosis. However, there is overlap between symptoms in this condition and those in conventional clinical diagnoses. Common problems in deriving an accurate differential diagnosis are discussed. Implications for treatment are also reviewed, with an emphasis on a comprehensive approach to treatment that supports the client’s norms and values.

Hans Rohlof, Jeroen W. Knipscheer, and Rolf J. Kleber, “Use of the Cultural Formulation with Refugees

This article discusses the experiences of mental health professionals who applied the Cultural Formulation (CF) of the DSM-IV for assessment of psychopathology and treatment needs of refugees in the Netherlands. The CF approach proved to be a useful tool in the assessment and diagnostic phase of clinical treatment. However, patients reported problems with defining their own culture and providing explanations of illness and therapists had difficulty identifying culturally-based difficulties in the clinical relationship. Additional information was needed about working with interpreters, therapists’ attitudes towards the culture of the patient and towards their own culture, patients’ previous experiences with discrimination and inaccessibility of care, gender issues, and specific cultures and subcultures. A more structured approach to conducting the CF is recommended. We developed the “Cultural Formulation Interview” for this purpose. The adaptations are aimed at improving the CF for use with refugee populations, as well as for more general use in transcultural psychiatry.

Luis Caballero Martínez, “DSM-IV-TR Cultural Formulation of Psychiatric Cases: Two Proposals for Clinicians

This article reviews some limitations of the current guideline for the DSM-IV-TR Cultural Formulation (CF) from the perspective of psychiatric practice that are based on the author’s experience conducting doctoral courses on cultural psychiatry from 1996 to 2007 in the Department of Psychiatry at the Universidad Autónoma de Madrid (Spain). Two proposals are presented for facilitating use of the CF by general clinicians. These proposals offer a procedure for embedding only the most relevant clinical information in a psychiatric history, followed by a brief cultural formulation. The approach is illustrated with a clinical case. Although the CF has considerable promise for revealing knowledge about patients, health practices, and health systems that is essential for clinical care, substantial research must be carried out to facilitate widespread use of the CF in clinical practice.


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