DSM-IV Outline For Cultural Formulation Research Articles

The Evolving Culture Concept in Psychiatric Cultural Formulation: Implications for Anthropological Theory and Psychiatric Practice.

For thirty years, psychiatrists and anthropologists have collaborated to improve the validity of psychiatric diagnosis. This collaboration has produced the DSM-IV Outline for Cultural Formulation (OCF) and the DSM-5 Cultural Formulation Interview (CFI). Nonetheless, some anthropologists have critiqued the concept of culture in DSM-5 as too focused on patient meanings and not on clinician practices. This article traces the evolution of the culture concept from DSM-IV through DSM-5-TR by analyzing publications from the American Psychiatric Association on the OCF and CFI alongside scholarship in psychiatry and anthropology. DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. After George Floyd's death and demands for social justice, the culture concept in DSM-5-TR emphasized social structures. The article proposes an intersubjective model of culture through which patients and clinicians work through similarities and differences. It recommends a revised formulation that attends to clinician practices such as communicating, diagnosing, recommending treatments, and documenting, beyond collecting patient meanings. It also raises the question of whether an intersubjective model of culture prompts reconsiderations of culture-related text in other sections of the DSM. The social sciences can redirect attention to the clinician's culture of biomedicine to close patient health disparities.

Culture-bound syndromes in Aboriginal Australian populations

ABSTRACT Objective: This paper describes the validation of culture-bound syndromes with Urban (N=34) and Rural (N=31) Aboriginal participants. While culture bound syndromes have long been discussed in the international literature (see Cuellar & Paniagua, 2000), published empirical research with Aboriginal Australian populations remains absent. Critically, the secret nature of Aboriginal cultural practices presents additional research challenges which arguably do not impact to the same extent in other Indigenous cultures. The impacts on ensuring culturally and clinically competent assessment in the context of escalating rates of Indigenous suicide and mental health are significant. Method: Thematic analysis occurred with data generated from three phases of focus groups to address study objectives. The final stage involved a critical analysis of the DSM-IV Outline for Cultural Formulation (“OCF”) for the Aboriginal Australian context. Results: Validation of seven culture bound syndromes with predominant symptom consistency across locations is presented as well as determination of the cultural triggers implicated in the development of culture bound syndromes. Finally, an adaptation of the OCF is proposed to enable clinicians to undertake clinically and culturally valid assessment of Aboriginal clients. Conclusions: Practitioners are provided with guidance in the identification and formulation of culture-bound syndromes with Aboriginal Australian clients. KEY POINTS What is already known about this topic: (1) Anecdotal evidence of the existence of culture bound syndromes has been cited in a small number of papers. (2) Culture bound syndromes have long been discussed in the international literature. (3) DSM-IV Outline for Cultural Formulation (“OCF”) ensures guidance for practitioners around the formulation of culture bound syndromes. What this topic adds: (1) Empirically validates the existence of culture bound syndromes with Aboriginal Australian populations for the first time. (2) Validates symptom consistency across urban and rural Aboriginal Australian environments. (3) Provides practitioners with guidance regarding the formulation of assessment with Aboriginal clients experiencing culture bound syndromes.

An Introduction to the Cultural Formulation Interview.

(Reprinted from Focus 2015; 13:426-431).

Qualitative Analysis of Cultural Formulation Interview: Findings and Implications for Revising the Outline for Cultural Formulation.

The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients-11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.

The development of the DSM-5 Cultural Formulation Interview-Fidelity Instrument (CFI-FI): a pilot study.

This paper reports on the development of the Cultural Formulation Interview-Fidelity Instrument (CFI-FI) which assesses clinician fidelity to the DSM-5 Cultural Formulation Interview (CFI). The CFI consists of a manualized set of standard questions that can precede every psychiatric evaluation. It is based on the DSM-IV Outline for Cultural Formulation, the cross-cultural assessment with the most evidence in psychiatric training. Using the New York sample of the DSM-5 CFI field trial, two independent raters created and finalized items for the CFI-FI based on six audio-taped and transcribed interviews. The raters then used the final CFI-FI to rate the remaining 23 interviews. Inter-rater reliability ranged from .73 to 1 for adherence items and .52 to 1 for competence items. The development of the CFI-FI can help researchers and administrators determine whether the CFI has been implemented with fidelity, permitting future intervention research.

Does the Cultural Formulation Interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site

Objectives. Cross-cultural mental health researchers often analyze patient explanatory models of illness to optimize service provision. The Cultural Formulation Interview (CFI) is a cross-cultural assessment tool released in May 2013 with DSM-5 to revise shortcomings from the DSM-IV Outline for Cultural Formulation (OCF). The CFI field trial took place in 6 countries, 14 sites, and with 321 patients to explore its feasibility, acceptability, and clinical utility with patients and clinicians. We sought to analyze if and how CFI feasibility, acceptability, and clinical utility were related to patient–clinician communication.Design. We report data from the New York site which enrolled 7 clinicians and 32 patients in 32 patient–clinician dyads. We undertook a data analysis independent of the parent field trial by conducting content analyses of debriefing interviews with all participants (n = 64) based on codebooks derived from frameworks for medical communication and implementation outcomes. Three coders created codebooks, coded independently, established inter-rater coding reliability, and analyzed if the CFI affects medical communication with respect to feasibility, acceptability, and clinical utility.Results. Despite racial, ethnical, cultural, and professional differences within our group of patients and clinicians, we found that promoting satisfaction through the interview, eliciting data, eliciting the patient's perspective, and perceiving data at multiple levels were common codes that explained how the CFI affected medical communication. We also found that all but two codes fell under the implementation outcome of clinical utility, two fell under acceptability, and none fell under feasibility.Conclusion. Our study offers new directions for research on how a cultural interview affects patient–clinician communication. Future research can analyze how the CFI and other cultural interviews impact medical communication in clinical settings with subsequent effects on outcomes such as medication adherence, appointment retention, and health condition.

Developing cultural competence in health care professionals: a fresh approach

For the past 20 years, cultural competence initiatives in medicine have addressed quality improvement, language access, refugee health and systemic racism. Many initiatives encourage postgraduate trainees to share their biases in caring for diverse patients. However, trainees may feel disappointed and insulted when such initiatives assume no prior exposure to cultural competence programming, are viewed as efforts towards ‘political correctness’ rather than skill development, and presuppose social distance among patients and providers.1 Medical educators need new cultural competence models as globalisation makes cross-cultural service provision a worldwide phenomenon. We designed a course around hypothetical recommendations that cultural competence initiatives should anticipate trainee resistance, occur early in training to make a professional difference, include case-based learning and avoid uncomfortable self-disclosures.1 All second-year psychiatry trainees (n = 12) at Columbia University underwent a 12 week course based on the Cultural Formulation Interview (CFI). The CFI consists of 16 questions and will be included in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V); prior DSMs have had wide international circulation. The CFI revises the DSM-IV Outline for Cultural Formulation, the cultural assessment with the largest evidence base in psychiatric education. The first 5 weeks consisted of reviewing social science theories underpinning CFI development (curriculum available) and residents sharing experiences surrounding their acculturation processes as doctors and psychiatrists. The last 7 weeks consisted of practising the CFI as classmates reviewed one-page summaries of CFI questions and answers with current patients. In each 50 minute lecture, instructors reviewed learning objectives, encouraged discussions on how cases corroborate or refute CFI social theories and solicited course feedback. Instructors met with trainees outside of class to examine how culture affects diagnostic assessment, treatment planning and continuity of care for each patient presentation. All trainees stated that they had cultural competence training in medical school. They appreciated the individual approach to culture in the CFI that avoids stereotyping patients through broad generalisations (‘the Asian patient’, ‘the immigrant’, etc.). Certain themes elicited high participation: (i) trainees discussing their own acculturation within the cultures of medicine and psychiatry, (ii) cross-cultural miscommunication despite using hospital cultural and linguistic brokers, and (iii) The relevance of cultural competence to formulating and implementing care for actual patients. The least participation occurred when trainees were asked to reflect on their racial, ethnic, linguistic or socio-economic backgrounds in relation to individual patients. Trainees may find self-reflection in cultural competence initiatives more productive when they can discuss professionalisation experiences or actual cases leading to skill development. This mode of self-reflection may feel less threatening than asking trainees to imagine how their attitudes or biases affect clinical care. Future studies can examine whether this model of cultural competence elicits feasibility and acceptability with larger trainee samples over time.

AACAP Helps Psychiatrists Address Patients’ Cultural Factors

AACAP Helps Psychiatrists Address Patients’ Cultural Factors

Use of an Expanded Version of the DSM-IV Outline for Cultural Formulation on a Cultural Consultation Service

Use of an Expanded Version of the DSM-IV Outline for Cultural Formulation on a Cultural Consultation Service

Use of an Expanded Version of the DSM-IV Outline for Cultural Formulation on a Cultural Consultation Service

This study assessed cultural consultants' impression of the utility of an expanded version of the DSM-IV Outline for Cultural Formulation in cultural psychiatric consultation and identified ways to improve the usefulness of the cultural formulation. A structured interview and questionnaire on the use of the cultural formulation was administered to 60 consultants working for an outpatient Cultural Consultation Service (CCS). Most consultants (93%) found the cultural formulation to be moderately to very useful. More than half (57%) had little or no familiarity with the cultural formulation before working with the CCS. The main suggestions for improvement of the cultural formulation were to expand sections on migration experience and include sections on religious and spiritual practice. Although many consultants had little previous familiarity with the cultural formulation, most found it useful in organizing their assessment and preparing consultation reports. The cultural formulation is a useful tool for nonmedical consultants and culture brokers, as well as for clinicians.

DSM-IV Outline for Cultural Formulation: Bringing Culture Into the Clinical Encounter

DSM-IV Outline for Cultural Formulation: Bringing Culture Into the Clinical Encounter

Bland's Contributions Honored Via APA Award, Video

Bland's Contributions Honored Via APA Award, Video

The DSM-IV Outline for Cultural Formulation: A Critical Demonstration With American Indian Children

The publication of DSM-IV is notable for the improved coverage of cultural issues in the diagnosis of mental disorders. In particular, Appendix I of DSM-IV includes an "Outline for Cultural Formulation" (Outline) which assists the clinician in evaluating the impact of an individual's cultural context on diagnosis and treatment. However, the capacity of the Outline to facilitate the development of comprehensive cultural formulations for children and adolescents has not been established. In this article the use of the Outline with American Indian children is reviewed critically. Based on the Outline, cultural case formulations for four American Indian children were developed and their comprehensiveness was assessed. Applied to the case material, the Outline provided a clear template for the development of cultural formulations. Nonetheless, several gaps in the material required by the Outline were identified, particularly in the areas concerning cultural identity and cultural elements of the therapeutic relationship. Clinicians working with children should recognize the strengths as well as the limitations of the Outline and expand their cultural descriptions accordingly. Several additions to the text of the Outline that will facilitate the development of comprehensive cultural formulations specific to children and adolescents are proposed.