Interdisciplinary case discussions as a training modality to teach cultural formulation in child mental health

Abstract

The DSM-5 Cultural Formulation Interview (CFI) may become an important tool to help operationalize culture in the clinical realm. However, challenges exist in teaching its use to avoid the risk of stereotyping and oversimplification, which could result in misunderstanding and stigma. The aim of this article is to document whether the CFI can be taught using regular Interdisciplinary Case Discussion Seminars (ICDSs), proposed as continuing education in child mental health and as part of clinical rotations for new trainees. During a two-year evaluative research project, ICDSs were held monthly in three different primary care settings servicing recent immigrants in Montreal, Canada. ICDSs were recorded and analyzed to examine their effect on the cultural formulation process and focus groups were conducted to explore the subjective experience of the participant trainees and professionals. Results suggest that ICDSs are a helpful way to teach the use of the CFI. The group discussions helped participants to better capture the complexity of the cultural and social experience of the child and family by moving away from simple identity assignations, supporting an inquiry into structural dimensions, and considering stigma and inequality in their formulation. The multiple levels of diversity (individual, disciplinary, and interinstitutional) represented in the discussion groups helped clinicians to understand the cultural formulation as situated in a specific relational context and a particular moment and, in so doing, helped trainees to avoid cultural formulations that essentialize culture.

Keywords

child mental health cultural competence Cultural Formulation Interview DSM-5 interdisciplinary case discussion training

Introduction

The Cultural Formulation Interview (CFI) is a set of interview guidelines developed to support the collection of information related to a patient's past or present cultural and social values and environment, with the aim of enhancing the clinical understanding of the problem and the treatment plan, and of strengthening the clinician–patient alliance (Lewis-Fernández, Aggarwal, Hinton, Hinton, & Kirmayer, 2015). The introduction of the CFI in DSM-5 responds to the need to operationalize the outline for cultural formulation (OCF) which was introduced in the DSM-IV in 1994 (American Psychiatric Association). It represents a clear recognition of the importance of taking culture into account in every aspect of patient care in psychiatry (Kirmayer, Guzder, & Rousseau, 2014). It can also be seen as an implicit acknowledgment of the fact that psychiatry and mental health are the product of a particular culture and that this needs to be taken into account in the clinical encounter (Kleinman & Benson, 2006). Although the CFI represents an important step towards drawing attention to culture in the clinical realm, the implementation of the CFI in clinical work represents a challenge. Kleinman and Benson (2006) underline the need to pay attention to the limits of the OCF and to be wary of possible unintended consequences of the CFI utilization, in particular the risk of stereotyping and oversimplification, which could result in misunderstanding and stigma (Lim, Diaz, & Ton, 2015). This raises the question of determining when and in which conditions the CFI can be an asset to clinical care.

As a set of questions, the CFI constitutes a potentially useful tool if the clinician is appropriately trained and knows how to use it in a sensitive and culturally safe way. However, teaching the use of the CFI is not a simple task. The trainees need to learn how to direct the collection of information with the CFI, how to synthesize the information obtained around the OCF, and finally, how to elaborate a treatment plan enhanced by new insights. Based on their clinical and teaching experiences, Rousseau and Guzder (2015) propose that cultural formulation in child psychiatry can be taught effectively through two experiential approaches: a cultural consultation service (CCS) (Kirmayer et al., 2014) and interdisciplinary case discussion seminars (ICDSs) (Rousseau et al., 2005), but this has to be verified through research.

Cultural formulation teaching: Added value to cultural competence training?

As an assessment technique, the CFI can be seen as a complement to existing programs and guidelines available to train adult and child mental health professionals to become culturally competent (Lim et al., 2015). Recent guidelines for training in medical school or in psychiatry emphasize an integrative approach with an intent to weave a concern for culture in the clinician's day-to-day practice (Fung, Andermann, & Lo, 2008; Kirmayer et al., 2012). While most cultural curricula include training in multiple areas, ranging from reflexive attitudes to specific skills, the integrative perspective recommends that training expands over part or the whole duration of the professional training in order to consolidate the acquisition of these diverse forms of knowledge (Lim et al., 2015).

In parallel, guidelines increasingly insist on the importance of direct clinical experience under the supervision of culturally trained clinicians (American Psychiatric Association, 2013). This supervision can be provided during specialized rotations, for example in a CCS, or in community rotations (Nadeau, Rousseau, & Measham, 2014). However, the relative lack of trained supervisors is a major limitation to compliance with this training objective (Rousseau & Guzder, 2015). Thus, other experiential modalities have to be developed and evaluated in order to provide hands-on experiences which allow trainees to uncover, recognize, analyze, and address the complexity of cultural influences on clinical presentations.

Although case study is a standard teaching method in medicine, its use to teach cultural competence has been the object of relatively few theoretical or research papers (Dinh, Groleau, Kirmayer, Rodriguez, & Bibeau, 2012). Radley and Chamberlain (2001) propose that cases are storied accounts, narrative portrayals, whose analysis gives access to the clinician's information-collecting procedure and perspective. Case studies can be seen as a dynamic interaction between the case presenters and a group who, by challenging or questioning the presenters, contribute to the emergence of a new understanding of the clinical situation.

ICDSs have been implemented by the McGill Division of Social and Transcultural Psychiatry as a training and continuing education method to enhance cultural competency in academic and clinical service settings. More recently, they have been considered as an appropriate modality to train clinicians to use the recently developed CFI (Rousseau & Guzder, 2015). ICDSs are based on the following three principles. First, training based on reviewing the clinician's own practices is efficacious because it takes into account real-life complexity and more directly addresses the clinician's emotions and cognitions related to patient–clinician interactions, as compared to training based on clinical material which is not directly related to the training clinician. Moreover, group discussions during case presentations can facilitate this hands-on learning and problem solving. Second, ICDSs promote experiential learning in a safe environment, which facilitates reflexivity and self-awareness. Learning to handle uncertainty and discomfort is key to understanding a story from the perspective of the family, youth, and other involved partners (Guzder & Rousseau, 2013). Third, because they are interdisciplinary and sometimes interinstitutional, ICDSs favor the emergence of a multiplicity of perspectives as emphasized in the CFI. This is particularly important in child mental health where formulation relies on weaving together different voices (Manassis, 2014). This diversity of voices mirrors well the clinical process of co-construction of meaning in the formulation and the elaboration of the treatment plan, which is at the heart of the OCF.

The aim of this article is to document the impact of a series of interinstitutional ICDSs on the case formulation process. The specific objectives are to describe the impact of the ICDS on: 1) information collection (nature of information, age-related specificity); 2) changes in case formulation (from initial to final formulation) in terms of degree of complexity (relative inclusion of sociocultural aspects) and in shifts in formulation; and 3) treatment plan development (confirmation of intuitions/actions, questioning of proposed interventions, opening of alternative avenues).

Methods

Setting

The study took place in Montreal, at public community health and social services centers providing general medical and mental health care for inner city neighborhoods with very diverse populations. In 2013, a two-year evaluative research project was conducted to document the impact of ICDSs on the case formulation process and the subjective experience of ICDS participants. ICDSs are held on a monthly basis in three collaborative care mental health settings which provide services for a large populations of new migrants (Nadeau et al., 2014). Members of an interdisciplinary group present the clinical history and are asked to formulate their understanding of the case at the end of this presentation (initial formulation). During ICDSs, the CFI and supplementary modules, including the informant version of the CFI, were not used as a systematic interview guide, but their areas of focus were used to illustrate areas of inquiry that could be explored further depending on individual cases. After the group discussion, a second formulation integrating new insights is proposed (final formulation). The group subsequently discusses the treatment plan with the presenting clinician or team.

Data collection

From October 2013 and April 2014, and again from September 2014 to April 2015, three different groups held monthly ICDSs for a total of 45 sessions (15 meetings per group: 7 during the first research year, and 8 during the second). Case discussions were audio-taped and transcribed verbatim. Focus groups were held with a sub-sample of participants at the end of each ICDS year. At the end of the first year, focus groups addressed participants' overall perceptions of ICDSs and their impact on their professional practice, while at year 2, they explored how participants felt that the ICDSs had helped them in their practices with culturally diverse families, and to what extent they sometimes felt destabilized and disturbed by sociocultural elements that had emerged during ICDSs.

Ethical approval for the study was obtained from the participating organizations and all seminar participants provided consent. All participants were bound by clinical confidentiality. Details of the case studies have been altered in order to preserve confidentiality.

Data analysis

The audio-recorded ICDSs and focus group sessions were analyzed qualitatively. A thematic analysis was performed on both sources of collected data following the standard process (Boyatzis, 1998). ICDSs transcriptions were read by four research team members and initial codes were developed and defined. The material was subsequently coded by the first two authors (CR & JJL), both experienced qualitative researchers. Coding categories were refined during research meetings and coding was reviewed throughout the process using NVivo10 software. Three broad categories were developed describing the impact of the group discussions on specific domains: 1) collection of information (nature of information emerging during and after the initial presentation, work around the meaning of information, group identification of missing information); 2) case formulation (biological, psychodynamic, systemic, social, cultural factors), the initial formulation and the final formulation; and 3) treatment plan (individual, familial, and sociocultural components), including questioning of cultural appropriateness of the past treatment plan and suggestions of cultural adaptation or alternative therapeutic modalities. The subsequent analysis emphasized the shifts from the initial to the final formulation and the impact of these shifts on the treatment plan. The presence of a shift was established if the final formulation had different case elements than the initial one. If the case elements remained the same, although more detailed, it was coded as “no shift.”

It is important to note that this analysis is not “culture-free” and reflects the authors' theoretical assumptions, stemming mainly from psychodynamic and systemic theory and from critical medical anthropology. Multiple theoretical perspectives can provide valuable insights to support case formulation, and their diversity can help to identify their respective contributions and blind spots. Clinicians need to be aware of the bias and limits of the tools they use and they must favor, as much as possible, a multiplicity of perspectives. The second component of the qualitative analysis concerned the subjective experience of ICDS participants. The focus groups' transcriptions were read and analyzed thematically to examine the research participants' evaluation of the ICDSs. For this article, the discourse of participants concerning the basic themes (collection of information, case formulation, and treatment plan) was analyzed to determine to what extent these categories spontaneously emerged from the participants' discourse as outcomes of the ICDS process.

Results

One hundred and five professionals participated in the ICDSs in the first year (30, 43, and 32 participants in each group) and 95 in the second year (33, 34, and 28 in each group). Most participants were present on a regular basis, with others occasionally present. In total, 154 different professionals participated in the ICDSs, since 46 participated in both years. ICDS participants included 130 practicing clinicians (84.4%) and 24 still in training (15.6%). Among the ICDS participants, 58 also participated in a focus group, either at the end of year 1 (n = 21), at the end of year 2 (n = 31), or, for some participants, in both years (n = 6) (see Table 1).

Table 1.

Characteristics of interdisciplinary case discussion seminars (ICDS) and focus groups (FG) participants.

	ICDS participants (n = 154)		FG participants (n = 58)
	n	%	n	%
Gender
Woman	137	89.0	54	93.1
Man	17	11.0	4	6.9
Age
20–29 years	30	19.8	8	13.8
30–39 years	55	35.8	23	39.7
40–49 years	38	24.5	13	22.4
50–59 years	19	12.3	9	15.5
60 and more	12	7.6	5	8.6
Organization
Health & Social Services	103	66.9	41	70.7
Youth Protection	39	25.3	11	19.0
Schools & School Boards	12	7.8	6	10.3
Domain of practice
Social Work	85	55.2	30	51.7
Psychology	27	17.5	15	25.9
Psychoeducation	21	13.6	8	13.8
Other	21	13.6	5	8.6

Forty ICDS meetings were audio-taped and transcribed verbatim over the course of the research period. While most meetings only concerned one clinical case study, two cases were presented during a meeting on two occasions. Therefore, a total of 42 cases were documented and analysed for the study (see Table 2). A variety of geocultural areas are represented in ICDSs' cases. It is important to note that categories presented in Table 2 are derived from the United Nations' statistical divisions and do not represent culturally homogeneous entities. They are used here for the sole purpose of description, in order to report on the variety of families' geocultural origins. Most families had lived in Canada for more than 10 years (20) or had one parent who was Canadian-born (8), while 14 families had immigrated to Canada less than 10 years previously. Cases were presented with a balanced representation in terms of children's age categories, with a higher representation of girls (35 girls and 22 boys). Certain families had more than one child presented as the identified patient; therefore the total number of children exceeds the number of cases (57 versus 42).

Table 2.

Characteristics of child cases presented during ICDSs.

	Cases presented during ICDSs (N = 42)
	n	%
Children's gender^a
Boy	22	52.4
Girl	35	83.3
Children's age^a
0–5 years	16	38.1
6–10 years	16	38.1
11–15 years	13	31.0
16 years and more	12	28.6
Household size
2–3 persons	16	38.1
4–5 persons	15	35.7
6 persons and more	11	26.2
Parents' years in Canada (longest if differences)
Canadian-born	8	19.1
Less than 10 years	14	33.3
10 years and more	20	47.6
Family geocultural areas of origin^b
Arab world	9	21.4
Caribbean	8	19.1
Central Asia	1	2.4
East and Southeast Asia	2	4.8
Europe	2	4.8
North America	4	9.5
South and Central America	2	4.8
South Asia	13	31.0
Sub-Saharan Africa	6	14.3
Clinicians' reason for presenting the case^c
Consultation about treatment plan (general)	40	95.2
Difficulties with assessment and diagnosis	18	42.9
Failure of all attempted interventions	18	42.9
Risk assessment (suicide, homicide)	3	7.1
Specific question on case orientation (placement, schooling)	7	16.7

Certain families had more than one child presented as the identified patient (therefore total exceeds 100%).

Certain families combined more than one geocultural area of origin (therefore total exceeds 100%).

Certain clinicians named more than one reason for presenting the case (therefore total exceeds 100%).

Finally, five main reasons for presenting a case were named by ICDS participants. While almost all presenters considered that the group discussion would help them with the treatment plan (40), many also expressed difficulties with the evaluation of the situation (in terms of assessment and diagnostic considerations, and formulation of the case) (18), and others expressed a feeling of being at an impasse as all previous interventions had failed (18). Another reason for presenting a case was to address specific questions about the orientation of a case (such as placement or schooling needs) and, less frequently, a consultation on the level of risk for suicide or homicide (3).

Impact of ICDSs on information collection

Widening and orienting information collection

The group case discussions always invited and supported a wide exploration of the psychosocial sphere. Length of participation by participants in the ICDSs was associated with more comprehensive assessments of the psychosocial and cultural sphere. At the beginning of the year, new participants would often present families in rather schematic terms, usually emphasizing a single identity category for a child or family, referring to the national (e.g., Sri Lanka), ethnic (e.g., Tamil) or religious (e.g., Hindu) identity, while rarely to a combination of these. During the case discussions, the other participants would inquire about other identity levels, making apparent the heterogeneity of each of these categories. The following case material illustrates how questioning in the ICDS revealed this complexity:

A family from Rwanda was presented as a situation of conjugal and family violence in which the father is the aggressor. Because of this situation, the children had not been in contact with their father for more than two years in order to protect them from him. The group discussion revealed that the marriage was mixed, Hutu–Tutsi. The father came from a mixed family whose Tutsi members were all assassinated during the genocide, except for his mother, who was Hutu, and he himself who, because of patrilineal transmission, is Tutsi. His wife's family members were powerful in the Hutu military that perpetrated the genocide. The father's terrible feeling of guilt because of his survival seemed to be associated with the fact that he had not contested his wife's allegations that he was an aggressor, in spite of the fact that he was a warm father, that the children were attached to him, and that there was no evidence of physical abuse, beyond the use of mild corporal punishment.

In this case, the discussion transformed the participants' and the presenting clinicians' vision of the case. The turning point was the shift from the perception of a Rwandan family with intra-familial conflicts, to a Hutu–Tutsi family reenacting unresolved and unspoken trauma linked to the genocide.

After attending ICDSs, new participants presented their cases with increasing complexity. With time, the genograms that case presenters drew to display the family's relationships evolved from a schematic nuclear family representation to a more complex representation encompassing three (and sometimes four) generations. Participants also learned to unpack simple identity categories. For example, in cases of “Muslim” families, they would further inquire to find out if they were Shia, Sunni, or belonged to another group, and would ask questions to get a sense of the relative importance of religion in terms of the family's social network, gender and familial roles, and of the role of religion in terms of individual family members' spiritual support.

Child development and culture

Age-related cultural specificities were another domain that participants learned to explore. As a departure point, the naming process, which situates a child in the parents' dreams and expectations and often in continuity or in rupture with both families' lineages, was often explored in case discussions:

The case of a six year-old boy with violent and hypersexualized behaviors was discussed. His mother was from Tunisia and his absent father from Sub-Saharan Africa, but the boy did not know his father's name. Because the boy was considered a “demon” by his mother, she refused to use the child's birth certificate name and called him “Malak,” meaning “angel” in Arabic. The split between the hidden name and the new attributed name represented powerfully the splitting processes which were at stake in this case.

Expectations about children's roles in their families vary with culture. They may be negotiated around special transition markers indicating a certain level of maturity and these transition markers may represent shifts in social status. The discussion of these age-related transitions helped to explore the place of a child in a family and to clarify the dynamic:

A team of clinicians presented a 13 year-old Hassidic boy with a diagnosis of Asperger's syndrome, presenting increasing obsessive-compulsive symptoms, who had stopped going to school and had recently refused to do his Bar Mitzvah. The group discussion uncovered the fact that he felt rejected by his mother and had voiced that he did not belong anywhere. His father was withdrawn, and had been disqualified by his mother, but indirectly the boy expressed a wish to become a “scribe” like him.

The group discussion modified the understanding of the refusal of the Bar Mitzvah, from a symptom-related impairment to an inclusion of a symbolic representation of the unbalanced family dynamic, culture being used here to represent the boy's feeling of being excluded from a larger community and from his family.

Reading cues and identifying missing information

Within the discussion, the widening of the information-collection process followed directions that have been proposed in the CFI core or supplementary modules. The interactive discussions taught the participants to not only explore the different dimensions of the past and present history of the child, family and community, but also to focus on aspects which could be meaningful for the clinical management. Rather than moving into a “fishing expedition,” which can be a risk of using an extended tool like the CFI, the group discussions helped participants to identify particular cues which needed further exploration because they could be significant in terms of a family's understanding of a problem or of their help-seeking trajectory:

The mother of a Senegalese 15-year-old boy was presented as the third wife of her uneducated elderly husband. The presenters assumed this to be in line with the cultural norms of her community. Further unfolding of the story revealed that she had much more education than her husband, came from a family of higher social status, and that her father had already lived abroad when she married. The discussion suggested the presence of a family secret (possibly a sexual transgression), which could explain why such a marriage had been arranged for a young and beautiful girl. This directed attention to the family dynamics, which were at first considered consistent with cultural norms, when in fact, they suggested a likely problem.

In this case, the departure point was an arranged marriage, which may simply represent a collective norm. The cue calling for further questioning was the fact that a young, beautiful woman from an educated and wealthy family had been given as a third wife to an elderly husband belonging to lower social class. This cultural dissonance required further attention, although it might uncover experiences which were not associated with the culture of origin of the family.

The group discussion supported a decentering process through which the presenting clinicians began to speak about their clients' personal, familial, social, and cultural resources in these difficult cases. This in turn led them to identify missing information which could then contribute to the overall formulation. The issue of missing information and the handling of it is an important aspect of the case discussions. On the one hand, one of the CFI's main objectives is to train clinicians to gather as much sociocultural information as possible in order to do a complete assessment. On the other hand, within this process clinicians need to learn to respect and deal with the resistances and the silences of a child or family during the history-gathering process. The group discussion often centered on the gaps in the patient's story and their association with memory processes (particularly in trauma situations), with intra-familial secrets, or with defensive avoidance stemming from personal or collective experiences of discrimination.

The case of a 3-year-old girl with severe language delay and relational problems was presented. She had witnessed significant conjugal violence. Her father, a refugee from Liberia, was a religious Muslim. Her mother was from a Northern Canadian Indigenous community. There were significant gaps in both parents' stories. The mother refused to speak about her own father's death and the group had fantasies about a possible suicide. The father kept the clinicians at a distance and refused to speak about his personal life. Both post-traumatic avoidance and distrust coming from experiences of discrimination in the host country appeared to be at stake. The exploration of the use of language in the family revealed that the girl was exposed to four different languages at home and at daycare. The group discussion addressed the multiple obstacles to communication in this family (multiplicity of languages, trauma, discrimination, and possible constitutional factors) and the need to consider all of these to address the child's symptoms.

Balancing an emphasis on symptoms with a focus on strengths and resources

The analysis of ICDSs suggested that clinicians' feelings of helplessness sometimes led them to overemphasize symptoms in their case presentations. Overly detailed descriptions of behavioral or emotional symptoms were often used as a way to convince the group of the seriousness of a situation and to justify the fact that the clinician felt helpless. Symptoms associated with serious and immediate risks (suicidal ideation, self-mutilation, homicidal ideation, violent behaviors, and psychotic symptoms) were particularly associated with a long and repetitive symptom-focused discourse. Moreover, this emphasis implicitly conveyed the idea that the solutions needed were centered on diagnostic issues and on the management of psychopathology. Explanatory models were always explored by the presenters, but the group discussion revealed that this direct exploration had often been unsuccessful and that different layers of meaning emerged throughout the case discussion.

The group discussion almost always uncovered resources of the family which were previously either unrecognized or were presented as symptoms. For example, a street child presenting with delinquent behavior could also be seen as a survivor expert where his adaptive capacities could be mobilized to help recovery. In various cases, mothers who presented as helpless finally appeared as having an in-depth knowledge of the host country institutions and a good capacity to navigate them. Extended family members, transnational networks, and spiritual support were the most common resources which were identified during the group discussions.

Focus group participants concurred in saying that ICDSs were an effective way to learn how to collect information:

My perspective changed a lot [since I began to attend ICDSs], especially when I work with parents. It brought me a new approach. [It led me to] ask more questions about their migratory trajectory, about everything they did and experienced, about where they come from. (School psychoeducator)

I learned to be very patient. Some people come here [to Canada], but not always through the regular manner. To be able to search for this information, the family needs to really trust you. You need to know how to wait to be able to get this information. (Social worker)

We need to search, ask good questions, knowing that we may not get an answer, but that there may be something there. […] It opens possibilities [asking questions], shows our concern… and that there is not only one answer. (Social worker)

Impact of ICDS on case formulation

Initial case formulations, as presented by the clinicians before opening to discussion, were mainly centered on three broad categories: diagnostic considerations, family dynamic issues, and youth/family–clinician alliance (including relations with youth protection agencies, schools, and daycare). After the group discussions, final formulations almost always emphasized three processes: First, the contribution of context and culture in the emergence and evolution of illness (in all cases). Second, the awareness of the cultural dimensions of the institution/clinician and patient/family relationship. Finally, the integration and complementarity of the different theoretical frames of understanding, including the psychodynamic, cognitive, systemic, and cultural/social models, and also sometimes the genetic and medical models.

Shifts in formulation: Diagnosis and family dynamics at the forefront

In a majority of cases, the discussions led to a significant shift in formulation which could sometimes suggest envisioning a change in diagnosis, and which would often alter the psychodynamic, cognitive or systemic understanding of the case. Very often, the presentations uncovered significant present or past traumatic experiences and daily hassles which had been either ignored or not given a lot of importance in the initial overall understanding of the case:

In the case of a 15-year-old Nigerian girl, the initial formulation emphasized ADHD, Conduct Disorder, and substance abuse in a youth living in a family which was presented as dysfunctional and poorly integrated in the host society. The final formulation suggested that a complex PTSD diagnosis could provide a more appropriate way to understand this adolescent's acting-out symptoms and difficulties in concentration, which may have stemmed from a reenactment of an ongoing conjugal violence, physical abuse from a brother, sexual abuse which she experienced before immigration, and the emotional unavailability of her parents, who were overwhelmed by survival issues after immigration. Her parents' divergent explanatory models for their daughter's difficulties (her mother thought she was “possessed,” while her father considered her to be “a princess”), conferred on the girl a special status in the family. She embodied this splitting dynamic by being simultaneously overinvested, and rejected and feared, thus remaining alone and out of control.

In other cases, the shift in formulation characterized the clinician's new perception of family dynamics. Commonly, parents were initially described directly or implicitly as having personality disorders (“difficult and resistant”), while the final formulation emphasized the importance of cultural or environmental factors in understanding their behavior. In the following case, historical and transgenerational trauma in both parents' backgrounds shed some light on their behavior patterns:

In the case of a 1-year-old boy whose father was from Algeria and mother of Chinese origin (from a family in Canada for multiple generations), the initial formulation centered on the dysfunctional couple relationship and on possible personality disorders in both parents, which would account for the conjugal violence and family chaos. The final formulation, although not dismissing possible personality issues, indicated that the mutual construction of the “other” as the aggressor could also be associated with the parents' collective colonization history. The father's family's humiliation and discrimination in the suburbs of Paris had pushed him to become streetwise. His survival strategies led him to play with limits and transgress laws which he never considered legitimate because of the social exclusion and ostracism his group was undergoing. The mother's family survival strategies in Canada stemmed from a time in which Chinese immigrants were slave-like workers on the railways and were, on the contrary, focused on hard work to the expense of emotional and family time. She felt it was her mission to save the family, but she was emotionally unavailable to her baby. The parents' collective histories shed light on the way they endorsed their respective identities and on the strategies they used to face adversity.

The change in formulation in this case is composed of multiple shifts. Not only does it involve potential diagnostic implications (from personality disorders to chronic stress-related disorders) but also a transformation of the clinician's perception from a split or polarized view of family members (as good or bad, victims or aggressors) to a more comprehensive appraisal of social suffering and diverse singular reactions to it. Group discussions very frequently supported shifts moving away from a split vision of families and invited a reinvestment of all their members.

Holding uncertainties

In a relatively small number of cases presented at the ICDSs, there was no notable shift between the initial and final formulation. In most of these cases, the group discussion failed to elicit an alternative understanding which could have opened new perspectives. The group supported the presenting clinicians by validating some of their perceptions. Sometimes, the feelings of helplessness of the presenting teams elicited some frustration in the group. This would be manifested through repeated questions which could provoke defensive withdrawal in the presenting team. The acknowledgment of the teams' difficulties in accepting their helplessness usually resolved these situations. Overall, the group provided a collaborative holding of the uncertainty and feelings of absurdity that were evoked by some stories, in particular those combining multiple levels of violence (domestic and organized). In these situations of pervasive loss, the group helped clinicians to preserve hope and to value the small solutions they could provide.

The way the ICDSs contributed to an enriched formulation was repeatedly highlighted by focus group participants. They emphasized that the multiplicity of understandings elicited around a case supported a systemic formulation which took into account the cultural and social dimensions of a person's experience:

We are weaving together a kind of tapestry which introduces different meanings at different levels. We use different reference frames. Multicultural, anthropological, psychological, etc. It's really enriching to see how we can gain a more global vision which allows us to begin to situate a person, […] to find multiple meanings to life experiences. (Psychologist)

Some participants indicated that the sense of safety in ICDSs helped them to shift their understanding of the formulation:

This is the way we can learn. We need to be secure enough to think. I am there to learn. I can be wrong. I can be right. I can have a certain vision of a situation, then understand that when one is in a matriarchal or patriarchal system, [things can be different]. (Social worker)

Impact of the ICDS on the treatment plan

After having discussed a final formulation, the participants proposed therapeutic avenues to the presenting team. Overall, suggestions can be regrouped into four large categories of action aiming at: 1) completing the assessment; 2) working on personal, familial, and network strengths and resources; 3) treating or healing the disorder (therapeutic interventions); and 4) coordinating all involved parties.

Completing the assessment

A first set of recommendations to the treatment team almost always addressed the need to obtain significant missing information about the child, family or extended network.

Participants and resource persons proposed sensitive ways to obtain this information, not only suggesting appropriate CFI questions, but also addressing the influence of the interview setting on the disclosure process and discussing the pertinence of working with interpreters as cultural brokers and as language interpreters. The intent of these recommendations was not to obtain a “complete” assessment, but to prolong the exploration of the psychosocial and cultural realm in a manner which could be acceptable to the youth and/or family and meaningful for the treatment plan. In addition to providing significant information for case management, this process of identifying missing pieces also transmitted the idea of the assessment as a dynamic process which could extend beyond the first encounters or the initial written case report.

In certain cases, recommendations also were made for specialized psychological (e.g., neuropsychological testing) or medical assessments (e.g., iron deficiency and thyroid functioning). Although quite straightforward procedures, these basic investigations are sometimes forgotten when clinicians are struggling to understand a complex story which challenges their capacity to organize information and give meaning.

Working on strengths and resources

Three main types of recommendations targeted strengths and resources. The consolidation (or reconstruction) of a solid self, grounded in diverse identities, was often at the forefront, and was key in mixed couple dynamics and for at least first- and second-generation immigrants. In addition, as youth tend to be attracted by marginal identities, which may represent their feelings of exclusion, these identities also needed to be considered.

This was the case for a 16 year-old boy from Pakistan who was cognitively limited and became homicidal because he felt rejected by his family:

He does not feel Muslim… He is looking for other identities to borrow (gangster-illuminati), all having in common to be both marginal and powerful. This can be addressed in different ways. Often with youth, verbal expression has a limit and a life scrapbook could be a way to work on this. A life album with collage may provide means to represent all his identities, marginal ones with photos of gangster, illuminati and all that, but also the Pakistani side. This could raise the question: is it also possible to be Muslim? And how? So introducing the idea of multiple identities rather than the quest for a single founding identity.

This quote illustrates how the resource person encourages the group to gently challenge the split position of the youth (his rejection of his multiple identity), seeking to establish some bridges with the identities valued by his family in order to facilitate ways of belonging to both the youth culture and to his family and community of origin, thus minimizing the experience of exclusion.

Suggestions to establish or strengthen a support network and provide emotional safety were a second core category of treatment recommendations. Issues of attachment, emotional availability of parental figures, connection-reconstruction with extended family networks in the country of origin (through Skype for example) or host country, and support from non-family networks were considered:

In the case of a Roma family with six small children, the clinicians had emphasized the fragility of attachments and numerous problems in parental skills. While discussing the management plan, disagreement occurred between those who felt the children needed to be placed and those who, although worried for the children, felt that placement would further jeopardize the attachment between the children and the parents and that, given the likelihood that the family would be expelled from Canada, this would cause even more harm to the children. This latter position prevailed and the group worked around suggestions to place the school and daycare in the position of a surrogate extended family while the family remained in Canada. The presenting clinicians were also supported in their mourning in moving from an idealized to a hopefully “good enough” solution.

Finally, wider network interventions through advocacy were also often mentioned. These targeted the families' basic needs (food banks, housing, etc.), measures to support integration (language courses, employment, leisure activities, summer camps), and support for migratory procedures (obtaining refugee status, residency, or family reunification).

Making specific treatment recommendations

A first set of specific therapeutic recommendations often challenged potentially ethnocentric interventions. Very commonly, the management of disciplinary and daily routines by families was at stake. For example, clinicians would initially recommend “time out” to African families, although this could be interpreted by the family as very inappropriate because the children could feel abandoned and excluded from the group. Other parenting techniques to manage discipline and routines were then explored. Attitudes towards physical discipline were also addressed. For example, the use of “the slipper” to discipline children in the Middle East was initially presented as a sign of severe abuse by clinicians, when the group would introduce that it could be seen as much less damaging or hurtful than a hand slap by the families.

A second set of recommendations suggested alternative treatment modalities to complement standard treatment (e.g., CBT) or to replace it temporarily, if the proposed therapeutic modality was unacceptable to the family. These alternative propositions often put forward traditional or spiritual means of healing. In a situation of conjugal violence in a mixed couple, for example, the imam was perceived by the father as a legitimate authority. The youth protection worker, after discussion with the group, decided to work with the imam on stabilizing the family dynamic, rather than referring the couple to family therapy. The underlying assumption was not a generalization about the role and capabilities of imams, but a specific recommendation based on this particular couple's dynamics. Without pushing participants to take a stance vis-a-vis spiritual and traditional therapy (which could be helpful or harmful, just as any type of therapy could be), they were encouraged to explore the different modalities through which families could “protect” themselves, and to discuss the eventual complementarity of these protection processes with other aspects of treatment. Some recommendations also proposed adaptations of standard treatments in order to increase their cultural acceptability and efficacy. For example, in play therapy, it was proposed that the symbolic figurines used for play be expanded to better represent the child's world, or a specific expressive modality (e.g., sand play) was proposed because of its high acceptability for parents coming from certain cultural backgrounds (e.g., North African and South Asian families).

Strengthening partnerships

The group discussions themselves also represented a step out of a silo approach. The need to coordinate diverse services, most often school, health services and youth protection services, was commonly mentioned as part of the treatment plan. Partners who were present from these different health and social service networks often began this coordination work during the break and finalized some follow-up meetings at the end of the ICDS.

Focus group participants acknowledged the fact that ICDSs helped them to enlarge the alternatives they could consider in the treatment plan:

I think it led me to widen my understanding of the problem, to think about contacting the uncle in Africa [group laughs] or things that we traditionally don't learn in school… going out of the usual paths, looking at the problem in a different way. (Social worker)

In this last quote, the participant remembered being destabilized at first when the group suggested that she involve the extended family and activate transnational networks, as this made her realize her own cultural focus on nuclear families:

It doesn't just help us for the presented case, but it supports our reflection in other cases. I am convinced that when we discuss a case, we think about a lot of other cases, and we put into practice things that we have heard. So it does have an incredible impact. (School psychologist)

Discussion

The subjective perceptions of participants converged with the content analysis of the group discussion transcriptions in suggesting that ICDSs are a potentially useful approach to teach CFI utilization both for new trainees and for practicing clinicians working in mental health from different disciplinary perspectives.

The group discussion analysis showed that ICDSs encouraged clinicians to widen the scope of their information collection, which is the main objective of the CFI, in order to better capture the complexity of the cultural and social experiences of patients and families. Moving away from simple or monolithic assignments of identity, the ICDS discussions supported inquiry into structural dimensions linked to social and economic factors associated with migration experiences. This invited participants to consider stigma and inequality in their formulation, and to avoid a “culturalizing” bias which would attribute problems or difficulties to adaptation as difficulties of the cultural “other,” thus minimizing structural and systemic dimensions (Metzl & Hansen, 2014). The simultaneous appraisal of overlapping dimensions of diversity, sometimes conceptualized as intersectionality (Cho, Crenshaw, & McCall, 2013), further protects against the risks of essentializing culture which result from assigning stereotypical representations to externally attributed identities.

The information collection analysis process also supported the idea that tangential questioning, which elicits cultural representations by being attentive to the patient discourse and following on the emerging cues, could be as effective, if not more effective, than a direct linear administration of the CFI core questions. Clinicians often reported that they had explored patients' and families' explanatory models with a lot of good will, but little initial success. Further discussion helped them to realize that they in fact already had a lot of significant information that they had not considered in their formulation. These observations converge with those of Ghane, Kolk, and Emmelkamp (2012), whose results suggest that indirect assessment of explanatory models of illness can help to move beyond social desirability and self-silencing, which may be associated with cultural gaps between the patient and the clinician.

Because training to integrate CFI dimensions and questions into the usual assessment is more complex than teaching trainees to administer core CFI questions or supplementary modules as separate parts of an assessment, these findings have critical implications for how to use the CFI in training. The fact that the CFI is much easier to use than the OCF is a clear advantage to promoting its use. However, this may also increase the risk of misuse if appropriate training is not given.

Results from this study suggest that the multiple levels of diversity (individual, disciplinary, and interinstitutional) represented in the group facilitated shifts from initial formulations to final ones. The impact of multiple voices and intersubjectivity on the cultural formulation has previously been highlighted by Aggarwal (2012). Underlining the fact that cultural formulation varies through levels of care and is closely associated with the clinical relationship, he proposes that this fluidity in cultural formulation needs to be taken into account in practice guidelines. ICDSs support the idea that a cultural formulation is a way to make sense of a clinical situation which needs to be situated in a particular moment and within a specific set of relationships. This means that the shift in formulation which occurs during the group discussion should not be considered as a final “expert” formulation but as constituting a first step in a process which will include repeated attempts to construct a shared, yet always fragmentary, understanding of the case. This leaves the clinician with a large share of uncertainty, which the group can help him or her confront and hold (Guzder & Rousseau, 2013; Kirmayer, 2013).

The influence of ICDSs on diagnostic shifts (in a fair proportion of cases) toward more stress-related disorders is one of the important findings of this study. Although based on a totally different sample of cases, it coincides with a study of a Cultural Consultation Service which demonstrated how, in cases referred with a psychosis diagnosis, the consultations led to a 49% change from the intake diagnosis to the final diagnosis which mostly consisted of stress-related disorders and mood disorders (Adeponle, Thombs, Groleau, Jarvis, & Kirmayer, 2012). This finding confirms the clinical pertinence of the CFI and its direct implications for the treatment plan. The other main shift concerned the relational context and in particular the relative investment by the clinical team in the different persons and institutions involved around an identified patient. Here again the group discussions supported the clinician's reflexive capacity and invited a transformation of assumptions. This process has been very well described by Katz and Alegría (2009), who demonstrated how clinical assumptions are not fixed attributes but rather occur between people and can be recognized and transformed through collaborative inquiries, which in some ways mirror the ICDSs process.

The ICDSs group discussions uncovered some of the potentially ethnocentric dimensions of certain treatment interventions. The supportive nature of the group facilitated this questioning because participants did not expect to be blamed, even if they could feel to a certain extent uncomfortable and destabilized by this questioning. The very interactive discussion about potential treatments and support avenues sometimes generated confusion for the presenters, however most of the time the discussion was perceived as providing concrete ways to enrich a treatment plan. It is interesting to note that in their evaluation of ICDSs, participants felt that they had gained a capacity to widen their range of solutions and became more attentive to elicit, understand, and sometimes validate solutions privileged by families.

Limitations

This study has a number of limitations stemming from its specificity. First, it is situated in a specific community-based collaborative care in mental health setting in three multiethnic neighborhoods welcoming a large population of new migrants. The clinicians and the trainees are thus immersed in a very diverse environment which may have, in itself, a very strong impact. It would be important to replicate this study in low-diversity settings in order to understand the ways in which the CFI teaching should be adapted to particular environments. Second, the interdisciplinary and interinstitutional nature of the clinical process is a very familiar issue in child mental health. In ICDSs, the diversity of the group (although not limited to child clinicians) favors the emergence of multiple voices. Studying mental health settings which are less interdisciplinary (or have different hierarchical relations among professions) would be necessary before concluding that this type of setting can work similarly in adult mental health settings. Third, the ICDSs did not study the use of the CFI as a screening tool in first assessment contexts (core modules) or in a direct cultural consultation context supported by an appropriate supervision. These other uses of the CFI need to be the subject of more research.

Conclusion

This study constitutes a significant step in documenting a training modality that can support the implementation of the CFI in clinical practice and teach its use both to trainees and to already-practicing professionals. At the administrative level, the implementation of such a training modality remains a challenge year after year because of the cost associated with the monthly liberation of clinical staff for a three-hour seminar. The staff enthusiasm and their mobilization to organize the ICDSs and overcome organizational space and time obstacles was the major factor which ensured a remarkable continuity of ICDSs over time.

The time dimension of the model, although demanding, appears to be a key element to achieve the integration of knowledge and an empowerment of the participants. The CFI as taught through case discussions promotes a complex vision of cultural and social understandings and may protect from adverse effects associated with the essentialization of culture. More research is needed to compare different CFI training modalities, and to study their impact on clinicians' actual practices and patient outcomes.

Footnotes

Acknowledgments

The authors wish to thank all research participants for their generous time and willingness to take part in the study. They would also like to thank anonymous reviewers whose insightful comments on the paper led to an improvement of the work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a research grant from the Fonds de la recherche en santé du Québec (FRSQ). The authors have no financial relationships to disclose.

Cécile Rousseau, MD, is professor of psychiatry at the Division of Social and Transcultural Psychiatry at McGill University and scientific Director of the Research Institute on health and cultural diversity SHERPA. She has worked extensively with immigrant and refugee communities, developing specific school-based interventions and leading policy-oriented research. Presently her research focuses on the evaluation of collaborative mental health care models for youth in multiethnic neighborhoods and on intervention and prevention programs to address youth radicalization.

Janique Johnson-Lafleur, MSc, is a doctoral student at the Division of Social and Transcultural Psychiatry at McGill University and a research coordinator at the Research Institute on health and cultural diversity SHERPA. She received her training in critical anthropology of health at Université de Montréal. Her research interests include cultural formulation and cultural competence training, ethical and political issues in transcultural clinical practice, collaborative care in youth mental health and participatory and mixed methods approaches to research.

Garine Papazian-Zohrabian, MA, PhD, is a clinical psychologist and associate professor of psychopedagogy and andragogy at the Université de Montréal's faculty of education. She is also a researcher for the Research Institute on health and cultural diversity SHERPA. Her clinical practice, research work and teaching expertise focus on child development and mental health, normal and pathological processes of bereavement, psychological trauma, their transmission and their impact on child adaptation to school and learning processes, and the construction of identity.

Toby Measham, MD, MSc, is an assistant professor at McGill University and a member of its Divisions of Social and Transcultural Psychiatry and Child Psychiatry. She is also a researcher for the Research Institute on health and cultural diversity SHERPA. Her clinical and research interests include transcultural child psychiatry and the development of collaborative community-based mental health care services for children and their families.

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