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

Debriefing evaluation

Patients and most clinicians appreciated the first few questions of the CFI because they provided space to elaborate details of problems and family contexts. Clinicians valued clinical insights from these first questions, which helped formulate differential diagnosis and treatment priorities. Patients typically found it difficult to immediately provide a name, and clinicians noted difficulty trying to elicit a name from them. Two clinicians suggested removing this question.

Causes, and stressors and supports

Themes and narratives of patient-perceived causes are summarized in Table 3, and they were similar for CMD and SMD patients. Some patients expressed the causes simply and straightforwardly. Others ruminated on the question, introspecting on the relationship of general principles and personal impact. The following account by a 36-year-old man with CMD illustrates such interplay of moral and physical weakness, and his own personal limitations:

Due to bad habits like gambling, one loses money and you go bankrupt. You regret becoming bankrupt, you feel depressed, sadness comes and you feel guilty. Due to bankruptcy, you are unable to do anything. When there is mental weakness (mana-durbalta), I gamble. In my opinion, mental weakness increases due to sexual urges (laingikta). If one continuously has sex, it causes weakness … Having sex every day is inappropriate and harmful, but I am unable to control the urge. I feel like having sex all the time … I told her [his brother’s wife] some made-up story and forced her to have sexual relations with me. I felt a lot of guilt, and I repent about what I did with my sister-in-law. But I could not control myself.

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Table 3.

Summary of causes and contexts of presenting problems (domain II).

Reported causes	Examples
1. Underlying physical illness	“I was born weak … I had jaundice (kavil) and ever since I have been having problems with [my] stomach.”
2. Psychological (preoccupied with thinking, cannot cope with criticism, tension or bitter disillusionment about the world)	“Thinking too much, ruminating and being absorbed in thinking the same thoughts over and over again.” “The world is an artificial place where good people don't receive what they deserve (dikhavat ki duniya).”
	“I feel sensitive, and then I get snappy … if people comment on my physical deformity.”
3. Family problems (spouse, in-laws, siblings, parents)	“Quarrels between me and [my] mother-in-law.”
	“If I have a spat with my husband … I don’t get to know what is going on in his head.”
4. Other interpersonal problems and conflicts outside the family	“If I am talking to someone [e.g., neighbour] politely and they rudely say, ‘Why are you sitting here, get up and get lost,’ then I get angry … My irritation (chid-chid) increases and I feel like slapping that person.”
5. Parental problems and upbringing	“At about 10 years of age, my parents got separated. My father had become an addict and so my mother left him … I lived in the town with my uncle … [my] aunt treated me like an outsider, a pariah.”
6. Problem with romance or marital matching	“I educated her … but she betrayed my trust and left instead. The one who genuinely respects [women] from the heart will be wronged.”
7. Unable to fulfil social and personal expectations	“I mean, on the one hand I want to do something different, but I feel society and I are at odds with one another.”
8. Sexual urges and impulsivity	“I was unable to stop thinking about ‘sex’; it went out of control. I fell a victim to my sexual urges and started having more mental problems because of guilt.”
9. Traditional cultural explanations (karma, spirit possession, black magic, healer-prescribed marriage)	“A Brahmin told me, ‘the spirits have captured you, and because of that you might have had your attack'. He suggested I get married. Once married, the [maiden] surname will change; the physical location will change; everything will change, including the family deity.”
10. Financial problems	“I encountered some financial hurdles about which I thought about over and over. If something happens unexpectedly, I feel stunned and shocked!”
11. Bereavement	“At home my grandpa was unwell; after that my sister died in the canal, that is why I felt like this.”
12. Work and environmental stressors	“Feeling inferior. Nobody gives me importance at my work place; often I felt that I wasn’t taken seriously, and my words had no value.”
13. Stigma and discrimination	“My friends would tease me. That made my problem worse.”

Debriefing evaluation

Patients appreciated the opportunity to discuss causes and contexts. For some, responding to these questions generated valued psychological insights. For example, the North Indian patient quoted earlier explained, “I am glad that this question was asked this time. Initially I thought that these things [pressure from family and relatives] trouble me, but now having shared this information I think that even I should work on some things about myself.”

Clinicians recognized treatment implications from their better understanding of patients’ perceived causes and social supports. They also valued the process of focusing on patients’ experience because it enhanced rapport in the clinical relationship. A clinician interviewing a 54-year-old man with hallucinations explained, “I feel that the cultural perceptions of cause, context and support are important elements, along with the patient’s understanding of his problem.” In some interviews, however, clinicians were frustrated when they were unable to elicit a relevant response.

Role of cultural identity

Many patients found it difficult to talk about cultural identity in response to the two questions about its impact, which was the focus of the cultural identity questions in the field trial version of the CFI. Although only a few expressed clearly positive or negative effects, most denied its negative impact on their condition (23/36).

For those describing adverse effects, cultural identity was framed with reference to stressful conditions and contexts, such as migration, place of origin, religion, caste, social norms, and problems with their in-laws’ family. Caste-related issues were woven into the discourse, but usually explicit only on probing. Differences between SMD and CMD accounts were subtle, although SMD patients seemed less inhibited in describing the negative impact of cultural identity.

Though accounts conflated elements of personal background and difficult social conditions, migration was most frequently linked to a cultural identity contributing to distress. Migration-related cultural issues typically emphasized how hard it was to adjust. Accounts referred to migration at various levels: within-city, between-cities, rural-urban, and international migration. Explaining problems from within-city migration attributed to conflictual cultural identities, an unemployed 27-year-old non-Brahmin man described his upbringing in a Brahmin community. Although his father owned a house in a multi-caste and multi-religious community, he had rented a house in the Brahmin community, drawn by the appeal of a cultured environment. Economic problems after his father’s death compelled the patient to return to the multi-cultural neighbourhood. After moving back, he encountered discrimination and stigma by others who regarded his background in the Brahmin community as pretentious:

When we moved from Sadashiv Peth (Brahmin locality) to Ganj Peth (multi-religious locality), people in Ganj Peth knew we had moved from Sadashiv Peth, and they believed that we were very snobbish. People from Sadashiv Peth are very cultured because many Brahmins live there. The life style is ‘Brahmin type’, and we would behave in the same manner … I mean our ‘level’ had become like that only. Everybody would think of us as Brahmins only, as our manners were also like theirs.

One patient explicitly associated her problem with low-caste status. The following dialogue between this 39-year-old English-speaking patient with SMD and her clinician interviewer indicates the importance of acknowledging the impact of cultural identity in establishing a therapeutic alliance.

Clinician: Is untouchability still practiced?

Patient: Yes. In Modi-Khana

Clinician: Do you mean to say that it is still practiced there?

Patient: Untouchability is still practiced everywhere …

Clinician: Oh, I didn’t think it was.

Patient: Where do you live?

Clinician: In India, but I didn’t think it was practiced in Pune.

Patient: Come with me and I will show you.

Debriefing evaluation

Some patients who understood and reflected on questions about the role of cultural identity appreciated the opportunity to talk about their faith in god; they emphasized the importance of religion, caste identity, and family values. A 50-year-old man with SMD explained, “Questions that asked me how I understand my illness and the question where I answered about attending religious programs to feel better were helpful.”

Notwithstanding initial difficulty understanding the question about the impact of cultural identity, with additional time on the topic, some came to value the question, as indicated in the following dialogue between a patient and the debriefing interviewer:

Patient: At first, topics related to culture are a little difficult to understand. I even told him [the clinician]. Because I hadn't thought about how being ill may affect my family. And I realized that it actually does affect them...

Clinician: What were those cultural questions?

Patient: What influence does your caste have on your illness? Whether your problems increase or decrease. [The] first time it is a little difficult to understand. It seems all is okay and has no impact.

Clinician: So, you have to put some thought into it?

Patient: We have to think, madam, because this is the first time I am facing such questions. Before this, doctors never asked me if your background has any impact on your problems. They ask [about symptoms] and I tell them, and I get my medicines.

Other clinicians, however, who did not elicit useful responses remained skeptical:

The patient could not understand the questions properly. We were unable to go beyond superficial issues despite much probing. The patient is illiterate. She restricted responses to symptoms and her relatives only. She was circumstantial or went off on a tangent. This could be due to the formal thought disorder … or it may be due to her being too preoccupied with her physical complaints.

Debriefing evaluation

Patients appreciated the chance to express grievances with previous treatment. This was clearer from their accounts than from their remarks in debriefing. Clinicians valued information about past help-seeking and barriers to current help-seeking, both for diagnosis and treatment planning. They typically noted that benefit but without elaborating.

I. Cultural identity of the individual patient

Domain I, which elaborates cultural identity, remains essentially unchanged from the original OCF. It refers to a comprehensive account of a patient’s background, considering “an individual's racial, ethnic, or cultural reference group” (DSM-5) and more. Assessing cultural identity requires an interviewer to focus on a patient’s self-ascribed identity, rather than the views of others or of the clinician. Our experience in the field trial was notable for some clinicians’ difficulties eliciting – and patients’ difficulties articulating – accounts of cultural identity with a useful level of detail. This was also a problem reported at other sites in the field trials (Bäärnhielm et al., 2016). The questions of the field trial version considered only the impact of cultural identity without first adequately clarifying what it meant for the patient. Revisions in the DSM-5 published version of the CFI and development of SM (Supplementary Module) 6 on cultural identity responded to these limitations. However, further research on eliciting and evaluating the role of cultural identity is needed, and the development of the supplementary module and related efforts indicate prospects for that.

II. Illness explanatory models

Interest in cultural explanations of a patient’s illness, domain II of the original OCF, has also been an enduring feature, not only of cultural formulation but also the field of cultural psychiatry itself. The DSM-5 modification of the OCF referred to “cultural conceptualizations of distress”. Our focus on illness explanatory models is mindful of usage of the term ‘illness’ in medical anthropology, referring to an affected person’s experience of a health problem and the nature of distress. Inasmuch as the cultural formulation itself is intended for clinical use, the term ‘illness’, rather than distress or problem, is appropriate. Our recommendation for use of the term ‘illness explanatory model’, rather than ‘cultural explanation’ or ‘conceptualization’, is intended to consolidate the broad interests of the illness explanatory model in a single domain, rather than spread these illness-related interests across domains. In the CFI various aspects of illness explanatory model are covered in domains II, III, and IV to preserve the flow of the interview (e.g., past and current help-seeking each placed in separate domains).

As explained in the recent second edition of the Textbook of Cultural Psychiatry, confusion about a misleadingly narrow focus on perceived causes discourages acknowledgement of the broader scope of Kleinman’s original formulation of the illness explanatory model framework (Weiss, 2018). Kleinman proposed illness explanatory models as “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (Kleinman, 1980). Consequently, the broad scope of interests implied by “notions” endorses the priority of a wider range of illness-related issues (Weiss, 2018; Lloyd et al., 1998), and the focus on illness should therefore not be limited to cultural ‘explanations’. Cultural implications of illness, its meaning, and what to do about it are all fundamental interests of the illness explanatory model framework. Cultural patterns and idioms of distress, priority symptoms, perceived seriousness, the pain of patient-perceived stigma, self-coping, past help-seeking experience, anticipated outcome, and current preferences for help are all relevant. These various facets of the illness explanatory model are therefore the designated focus of domain II of the OCF-R.

In our CFI data set, information about patients’ illness explanatory models came from questions in all domains of the CFI. Naming illnesses (CFI domain I) yielded various responses; perceived causes (CFI domain II, see Table 3) were wide-ranging and widely valued; accounts of self-coping and past help-seeking (CFI domain III) and current preferences for help (CFI domain IV) were diverse. This last point was most relevant in distinguishing patients with CMD, who had wider and more diverse past help seeking experience, from patients with SMD. Current preferences for help seeking often highlighted desires for medicines that bring quick recovery, and counselling that is directive and problem-solving in the context of a close, confiding clinical relationship that is benevolent and parent-like.

III. Key social relationships

Key elements of social relationships, acknowledging family and other interpersonal social stressors and supports, were addressed by questions in CFI domains II and III. They are consolidated in OCF-R domain III. The formulation of this domain also places the clinician-patient relationship in the broader context of social relations. The two are complementary, though fundamentally different: key interpersonal relationships elicited in the course of the CFI are for the most part elements of history and life experience that a patient brings to the interview. Asking a patient to comment on potential effects of a clinician’s cultural differences that may affect the clinician’s effectiveness is less a matter of a patient’s experience. It is more an indication of a new relationship that did not exist before the start of the assessment interview, even though past experience in clinical and other social relationships may be influential.

Key relationships with a spouse, parent or child, siblings, and in-laws were as important as expected in our patients’ accounts. Rich narratives explained interpersonal aspects of vulnerability, coping, resilience, and support; they confirmed the priority of family and neighbourhood relations, which were a substantial component of patients’ narratives.

The priority of the anticipated clinician-patient relationship had been addressed in domain IV of the CFI after questions about current help seeking preferences. Our patients uniformly denied any personal concerns about adverse effects of the clinician’s cultural background differences. Idealization of the doctor is consistent with traditional values, which are likely to limit acknowledgement of anticipated concerns about this relationship, especially in an initial assessment interview. If such concerns were to be expressed, they would probably reflect a seriously problematic prior clinical experience.

IV. Social, cultural, political and economic contexts

Protecting human rights of psychiatric patients and protecting the field of psychiatry itself from collusion and misuse of confinement and forced treatment for political control are well-recognized priorities of psychiatry (Freeman & Pathare, 2005). The field is less attentive, however, to the impact of social, cultural, political, and economic contexts affecting the lives of people in the world and the mental health of patients, apart from consideration of disorders defined by social or situational trauma, like post-traumatic stress disorder. Critics of the global mental health agenda have argued that additional consideration of the impact of relevant contexts and settings is required (Kirmayer & Pedersen, 2014; Cooper, 2016). Broader interest in the contexts of life around the world and their nonspecific effects on mental health problems have been acknowledged in the field of cultural psychiatry, but they are less visible in prior frameworks for cultural formulation. Sharpening the focus on this designated focus of OCF-R domain IV better acknowledges the priority of the topic.

Questions about contextual factors are included in domain II of the CFI, which is directly concerned with effects on the presenting problem of stressors and supports. Background issues associated with cultural identity in the CFI, such as the legal and financial issues that may complicate migrant status, are also relevant considerations for the proposed OCF-R domain IV. The relevance of contextual interests of this domain for the field of cultural psychiatry is acknowledged by several supplementary modules of the CFI that address key interests, including SM 4 on psychosocial stressors (Qureshi, Falgàs, Collazos & Hinton, 2016) and SM 5 on spirituality, religion, and moral traditions (Gellerman, Hinton, & Lu 2016). SM 11 for immigrants and refugees is also relevant, addressing pre-migration difficulties, migration-related losses and challenges, and how they relate to the clinical problem (Boehnlein, Westermeyer, & Scalco, 2016). SM 9 on children and adolescents (Rousseau & Guzder, 2016) and SM 10 on issues confronting older adults (Aggarwal & Hinton, 2016) similarly consider the influential contexts characterizing these two stages of life.

The impact of various relevant contextual issues is readily discernible from narrative accounts in our CFI interviews. Several study patients highlighted relevant concerns, and the structure of the OCF-R better acknowledges their relevance and priority. For example, a female artist complained bitterly about Indian culture lacking an “art mentality”. Another woman of American origin who migrated and became a resident of India acknowledged problems of the collectivist culture and the oppressive nature of caste. The Maharashtrian woman quoted in the results section on cultural identity explained the impact of cultural values affecting life with her in-laws with reference to “the Sangli-Satara-Kolhapur [regional] culture … [where] they harass daughters-in-law.” Other patients referred to the burden of cultural values that require copious spending on marriages and magico-religious beliefs that constitute barriers to rational choices for help seeking. Although some of these issues were elicited by questions on cultural identity or the illness explanatory model in the CFI, they also suggest the additional value of asking directly about aspects of political, economic, communal, terrorist, and other potentially relevant contexts of life in patients’ worlds. This may be accomplished by further revisions of the core CFI, and/or by further revising or adding one or more supplementary modules.

V. Overall cultural assessment

The final domain of the OCF-R and earlier versions involves summarizing the overall value of the cultural formulation and the relevance of the cultural formulation for diagnosis and clinical care. In that regard, reflections of the clinician on CFI findings and questions of the qualitative debriefing instruments used in the field trials may be more useful than the CFI itself. Such a debriefing question may be a worthwhile addition in a revised version of the CFI, inasmuch as experience with this instrument, like others used in psychiatry, is likely to lead to further revision.