Using the Cultural Formulation Interview in Denmark: Acceptability and clinical utility for medical doctors and migrant patients

Abstract

Previous studies have shown the importance of focusing on the cultural background of migrant patients in the psychiatric assessment. The Cultural Formulation Interview (CFI) offers a patient-focused approach to foreground the cultural context of the patient in the clinical encounter. Our objective was to explore the acceptability and clinical utility of the CFI for physicians and its acceptability for migrant patients seen at a transcultural mental health clinic in Denmark. In this study, the CFI was used in a second session following the standard clinical assessment to explore what additional information was gained from the CFI. Data on the use of the CFI data were collected immediately after the interview with questionnaires for medical doctors (MDs) (N = 12) and patients (N = 71). The findings showed that the CFI, in addition to standard assessment, was useful to the MDs for planning the treatment (60.0%) and for exploring the patients’ view on their cultural and social context (74.7%), but less so for the diagnostic process (9.9%). Patients reported high overall satisfaction with the CFI (93.0%) and viewed it as a welcome opportunity to tell their story. The findings add to existing knowledge on the CFI in terms of acceptability for patients of a primarily Middle Eastern origin and patients using an interpreter during the CFI session. Based on the findings of this study, the CFI is recommended to clinicians for treatment planning purposes and for exploring the cultural and social context of the patient.

Keywords

acceptability clinical utility Cultural Formulation Interview migrants psychiatric assessment

Introduction

Globally, the number of migrants, especially refugees, has increased in recent years (Bäärnhielm et al., 2017). By January 2017, 10% of the Danish population consisted of migrants and 58% of these migrants were of non-Western origin, originating from over 200 different countries (Statistics Denmark, 2017). In Denmark, a migrant is defined as a person who immigrated to Denmark and was born abroad by parents without Danish citizenship (Statistics Denmark, 2017). The increasing number of patients with diverse cultural backgrounds has posed new challenges to the Danish health care system.

A culturally sensitive approach to the clinical encounter can improve mental health care (Lewis-Fernández et al., 2014). Studies have shown that clinicians may experience difficulties in their daily work when communicating with, understanding, diagnosing, and treating people with cultural backgrounds different from their own (Nielsen et al., 2008; Jensen, 2013). When migrants in Denmark seek help, they experience less trust and empathy than the non-migrant population does in their encounters with health care professionals (Esholdt & Fuglsang, 2009). Such challenges in the encounter have been linked to lower levels of patient satisfaction (Ferguson & Candib, 2002). Because language, communication, and mutual understanding are central to psychiatric assessment, these challenges may be critical to the diagnostic process and treatment of migrant patients.

A culturally sensitive approach includes the ability to be aware of and understand culturally embedded health beliefs and practices (Flores, 2000; Betancourt et al., 2005; Kirmayer, 2012). Patients’ explanatory models affect their illness behavior as well as how they make sense of their illness and treatment (Kleinman et al., 1978; Janz & Becker, 1984; Kleinman, 1988). Clinicians’ capability to assess and understand these explanatory models has been shown to influence patient satisfaction with treatment, compliance, and clinical outcome (Young & Garro, 1982; Vermeire et al., 2001). A culturally sensitive approach may help reduce disparities in health care (Bennegadi, 2009). In a study from Sweden, the use of the Outline for Cultural Formulation (OCF) from DSM-IV, a framework that comprises four components and an overall cultural assessment (American Psychiatric Association, 1994), resulted in major revisions of diagnoses for 57% of patients (Bäärnhielm et al., 2015). Another study from Canada, using the OCF in a cultural assessment, showed revisions of diagnoses for 49% of the patients (Adeponle et al., 2012). To meet the challenges of patients with heterogeneous needs and cultural backgrounds and to provide all patients with equal access to good quality care, there is a need to develop methods and tools that are culturally sensitive (Bäärnhielm & Scarpinati Rosso, 2009; Bhugra et al., 2011).

The Cultural Formulation Interview

In 2013, the Cultural Formulation Interview (CFI) was published in DSM-5 (American Psychiatric Association, 2013). The CFI is a semi-structured interview guide that offers a systematic patient-focused approach to incorporate cultural awareness into clinical work. Experiences with the OCF were used along with literature review and consensus-building discussions to establish agreement on operationalizing the OCF into the CFI (Lewis-Fernández et al., 2017). The CFI consists of a core patient interview, an informant version, and 12 supplementary modules. The supplementary modules can be used for further exploration of themes in the CFI, such as explanatory models, levels of functioning, and social network, and four modules are designed for specific groups, such as school-age children and adolescents and refugees (Lewis-Fernández et al., 2016). The growing body of research on the CFI indicates that it can enhance patient-clinician communication, help build trust, and contribute to better mutual understanding in the clinical encounter (Aggarwal et al., 2015; Ramírez Stege & Yarris, 2017; DeSilva et al., 2018). The CFI aims to collect information that can be incorporated into a cultural formulation that, together with clinical assessment, should result in more culturally sensitive diagnoses (American Psychiatric Association, 2013). Accurate diagnosis is critical for the provision of appropriate mental health treatment. The CFI provides an opportunity for clinicians to learn about their patients’ lived experiences and explanatory models. Clinicians use this information to identify specific disorders in psychiatric nosology as well as identifying other psychosocial issues relevant to patient care. In DSM-5, it is suggested that the CFI is relevant to all clinical care but may be especially helpful in the diagnostic process when there are differences in the cultural backgrounds of patient and clinician (American Psychiatric Association, 2013).

The objective of this study was to explore the acceptability and clinical utility of the CFI for medical doctors (MDs) and its acceptability for migrant patients in Denmark.

Methods

Setting

The Danish public health care system offers services free of charge for anyone with Danish citizenship and for migrants with residence permit or registration certificate, which excludes asylum seekers (Ministry of Refugee Immigration and Integration Affairs, 2011; Pedersen, 2011). Patients with limited language proficiency must be offered interpreting assistance, and in the study period the interpreters were paid by the health care system. The interpreters used in this study were paid by the hour to assist with assessment and treatment. All interpreters were introduced to the present study’s different components as well as to the background and contents of the CFI. In the present study, 58.1% of the patients used interpreting assistance in the sessions. In 2010, standardized assessment and treatment courses for specific diagnoses with a predefined duration and content (Danish Regions, 2011) were introduced into the Danish mental health care system to ensure nationwide high quality and timely treatment (within four weeks of referral).

Data were collected at the following three clinics in the Capital Region of Denmark: the Competence Centre for Transcultural Psychiatry (CTP) at the Mental Health Centre Ballerup, where nine MDs included 62 patients (inclusion period: 1 June 2014 – 31 December 2014 and 1 June 2015 – 1 June 2016); the Outpatient Clinic Ballerup at the Mental Health Centre Ballerup (PAB), where one MD included three patients (inclusion period: 1 June 2014 – 31 December 2014); and the Section of Immigrant Medicine, Department of Infectious Diseases at the University Hospital Hvidovre (IMK), where two MDs included six patients (inclusion period: 1 June 2015 – 1 June 2016). An extra inclusion period at CTP (1 June 2015 – 1 June 2016) was launched because of a smaller contribution from the other clinics than expected and originally agreed upon. This was due to changes in personnel at the clinics.

PAB is a general outpatient mental health clinic. CTP and IMK are both tertiary outpatient clinics focused on migrant health. CTP is a competence center for specialized treatment, research, and knowledge sharing that offers assessment and treatment for mental disorders. IMK offers treatment for somatic disorders. High comorbidity exists between psychiatric and somatic disorders, and the clinical experience at IMK indicates that a high number of IMK patients suffer from mental health problems in addition to somatic illness. Therefore, we found it relevant to assess the acceptability and clinical utility of the CFI on the IMK-patient population (Lolk et al., 2016).

Study participants and data collection

The current study was based on 71 CFI sessions, after which data were collected using two questionnaires inquiring about the use of the CFI: one for MDs and one for migrant patients. Both questionnaires contained closed- and open-ended questions, generating quantitative and qualitative data, respectively. The CFI were conducted by 12 participating MDs with 71 individual patients. A standard session with an MD was estimated at 45–50 minutes, meaning that the CFI lasted up to a maximum of 50 minutes. The use of interpreters probably added additional time to the interview, compared with the time spent in earlier studies. The MDs included in the study were heterogeneous in terms of age, sex, and clinical experience. The MDs were asked to include all patients who fulfilled the inclusion criteria during the inclusion period. The MDs were not instructed to collect data on patients declining to participate, therefore no record was kept of this information. The inclusion criteria were: i) 18 years or older, ii) an migrant, iii) diagnosed with a mental disorder according to ICD-10 (World Health Organization, 2011) by a physician.

The MDs were all senior consultants in psychiatry or residents. For the purposes of training all the MDs participating in the present study to use the CFI and to collect data, the first and second authors used the same presentation. The presentation covered the historical background and rationale for developing the CFI, and included an introduction to the different versions of the CFI and another to the supplementary modules. Furthermore, video clips on parts of the interview were shown from a real-life consultation between the first author and a patient to illustrate the potential of the CFI. In the presentation, instructions on how to use the guide were given and all themes and CFI questions were fully reviewed one by one. Instructions were given on how to probe and clarify questions when the answers were inadequate. The MDs were instructed to follow the order of the 16 questions. The training lasted for 1–2 hours. All data collection material was covered in the training and the MDs had time to read printed versions and ask questions.

In the present study, the first session after referral consisted of a standard clinical assessment with diagnostic procedures and the gathering of basic demographic data performed by a physician. In the following session, the same MD carried out the core CFI (Anon, 2017a). Based on the clinical assessment and the CFI, the MD should compile an initial evaluation of the patient that includes assessment of psychopathology, diagnosis, and a treatment plan. The CFI was conducted in the second session in the present study in order to investigate the additional value gained from the CFI. For the data collection, the MDs filled in a questionnaire on whether the 16 CFI questions had been asked or otherwise covered in the session; this was meant to probe whether they had asked the specific question or whether the content corresponding to the question had already been spontaneously generated by the patient’s answers without the question having been asked by the MD. The questionnaire also contained closed- and open-ended questions on whether the CFI had changed the MDs’ understanding of the patients’ symptoms or diagnoses, or had contributed to a change in the content of the treatment plan. The MDs noted if any relevant additional information was brought forward during the CFI that had not been identified in the previous standard assessment. The migrant patients were asked to fill in a questionnaire on acceptability and satisfaction with the interview. The content of this questionnaire was adapted from the open-ended, semi-structured debriefing interview questions for patients from the CFI Field Trial (Aggarwal et al., 2013). The questionnaires were filled in immediately after the CFI. The data from the qualitative questions in this study were to contribute to the data from the quantitative questions and lead to a more in-depth description and understanding.

Data analysis

Quantitative data

The demographic data on the patients were analyzed with descriptive statistics, and the psychiatric diagnoses were grouped according to ICD-10 within the diagnostic chapters F00–99 (World Health Organization, 2011). The questionnaire data were analyzed to provide an overview of the MDs’ experiences using the CFI and the patients’ acceptability and satisfaction with the CFI. All statistical analyses were conducted in Stata 14 (Stata Corp, 2017).

Qualitative data

Text derived from the open-ended questions in both questionnaires was analyzed using systematic text condensation (Malterud, 2012), where a systematic approach was applied to code and categorize meaning units throughout the text. The codes were established when reading through the texts using the software NVivo 11 (Anon, 2017b). Subsequently, crosscutting codes were compiled into wider themes. The text from the open-ended questions was read several times to develop an overall understanding of it, and it was coded by both the first and second authors. These two authors then discussed and compared codes to reach an agreement on a set of codes and themes. To further secure agreement on the qualitative findings, codes and themes were discussed with the last author.

Ethical considerations

This study protocol was submitted to the Regional Committee on Health Research Ethics in Denmark (Journal no. H-3-2013-FSP61), but did not require ethical approval. According to §2 of the Danish Committee Act registry research projects, interview surveys and questionnaire surveys must only be reported if human biological material is included in the project. The protocol was approved by the Danish Data Protection Agency, and the project recognizes the Declaration of Helsinki II. The patients were informed about the study orally and in writing, and an interpreter was used for patients with limited Danish proficiency. All patients gave written informed consent before being included in the study. Participation in the study was not a prerequisite to receiving treatment.

Results

The sociodemographic characteristics of the MDs and patients are presented in Table 1. The majority of the MDs were females (83.3%), born in Denmark (75.0%), and residents (66.7%). The sex distribution in the patients was uneven, with 62.0% females and 38.0% males. Age and duration of stay were skewed. The median age was 44 years and the patients had a median of 18 years duration of stay in Denmark (interquartile range: 6–26). The population mainly originated from Middle Eastern countries: Iraq (17.1%), Syria (12.9%), Afghanistan (11.4%), and other Middle Eastern countries (24.3%). The distribution of psychiatric disorders within the ICD-10 diagnostic chapters was as follows: anxiety disorders (63.3%), depression (31.0%), schizophrenia (2.8%), personality disorder (1.4%), and attention-deficit/hyperactivity disorders (1.4%). Out of all anxiety-related disorders, PTSD accounted for 56.4% of the 63.3%.

Table 1.

Sociodemographic characteristics of physicians (N=12) and patients (N= 71), and patients psychiatric diagnoses.

Physicians	n = 12	%
Sex
Female	10	83.3
Male	2	16.7
Country of origin
Denmark	9	75.0
Sweden	1	8.3
Bosnia	1	8.3
Philippines	1	8.3
Level of experience
Senior consultant	4	33.3
Resident	8	66.7
Patients	n = 71	%
Sex
Female	44	62.0
Male	27	38.0
Interpreting assistance	43	58.1
Country of origin
Iraq	12	17.1
Syria	9	12.9
Afghanistan	8	11.4
Other Middle Eastern countries	17	24.3
North Africa	11	15.7
Eastern Europe	7	10.0
Asia	6	8.6
Psychiatric diagnosis
Anxiety-related disorder
PTSD	5	7.0
Other	40	56.4
Depression	22	31.0
Schizophrenia	2	2.8
Personality disorders	1	1.4
Attention-deficit hyperactivity disorders	1	1.4
	Median	Interquartile range
Age	44	35–52
Years since arrival in Denmark	18	6–26

Medical doctors

As illustrated in Table 2, the majority of the CFI questions were asked or otherwise covered in most cases. Three questions stood out as being asked less often than the others: questions 5, 10, and 15. Question 5 (“What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?”) was covered by 81.7% of the MDs; 77.5% covered question 10 (“Are there any aspects of your background or identity that are causing other concerns or difficulties for you?”); and 81.7% covered question 15 (“Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?”). The assistance of an interpreter did not affect the number of questions asked from the CFI compared to the patients not using the assistance of an interpreter (data not shown).

Table 2.

Cultural Formulation Interview questions asked or otherwise covered during the session (N = 71).

CFI item	n	%
Q1: What brings you here today?	71	100
Q2: Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?	70	98.6
Q3: What troubles you most about your problem?	71	100
Q4: Why do you think this is happening to you? What do you think are the causes of your [PROBLEM]?	69	97.2
Q5: What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?	58	81.7
Q6: Are there any kinds of support that make your [PROBLEM] better, such as support from family, friends, or others?	71	100
Q7: Are there any kinds of stresses that make your [PROBLEM] worse, such as difficulties with money, or family problems?	71	100
Q8: For you, what are the most important aspects of your background or identity?	70*	98.6
Q9: Are there any aspects of your background or identity that make a difference to your [PROBLEM]?	67*	94.4
Q10: Are there any aspects of your background or identity that are causing other concerns or difficulties for you?	55*	77.5
Q11: Sometimes people have various ways of dealing with problems like [PROBLEM]. What have you done on your own to cope with your [PROBLEM]?	70	98.6
Q12: Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for your [PROBLEM]?	68	95.8
Q13: Has anything prevented you from getting the help you need?	69	97.2
Q14: What kinds of help do you think would be most useful to you at this time for your [PROBLEM]?	67	94.4
Q15: Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?	58	81.7
Question 16: Have you been concerned about this and is there anything that we can do to provide you with the care you need?	69	97.2

*Missing case, n = 1 (1.4%).

Questions regarding clinical utility revealed that 28.2% of the MDs reported that the CFI was useful for gaining additional information on the patients’ symptoms, and only 9.9% reported that the CFI provided information that contributed to the diagnosing of the patients. In relation to improving treatment plans, 60.6% reported that the CFI provided useful extra information. The MDs reported that the CFI contributed with relevant new information compared to the standard assessment in 74.7% of the cases. The quantitative results on the clinical utility of the CFI from the MDs are shown in Table 3.

Table 3.

Physician evaluations of the additional value of the Cultural Formulation Interview (N = 71)*.

	Yesn (%)	Non (%)
Has the information from the CFI changed your understanding of the patient’s symptoms?	20 (28.2)	50 (70.4)
Has the information from the CFI changed your understanding of the patient’s diagnosis?	7 (9.9)	63 (88.7)
Can the information from the CFI be used when planning the treatment?	43 (60.6)	26 (36.6)
Has the CFI contributed with relevant new information that you did not obtain in your standard interview?	53 (74.7)	17 (23.9)

*The content of the table refers to the number of CFIs (N = 71), not the number of clinicians (N = 12).

In the qualitative analysis of data from the MDs, 21 codes were identified. Subsequently, the codes were collected in a crosscutting thematic analysis into four overarching themes: i) timing and value of the CFI information, ii) understanding of the patient, iii) the patients’ reflexivity and understanding of the questions, and iv) cultural background of the patient.

Timing and value of the CFI information

A recurrent finding in the qualitative data concerned the timing of the CFI during the assessment. Conducting the CFI after the standard assessment resulted in content repetitions and became a source of frustration for the MDs, who repeatedly reported that both symptoms and diagnoses were “thoroughly elucidated during the first assessment interviews” and that the “CFI didn’t change anything” because they “already had enough information.” Yet some MDs had a more positive framing of this repetition and reported “[The CFI] gave me confirmation that we are in fact dealing with PTSD and depression” and “The CFI supports that this is the right diagnosis.”

Understanding of the patient

This theme consists of feedback from MDs on new knowledge about the patient that was gained from the CFI. Several of these statements revolved around understanding the patients’ perspective on their mental and bodily symptoms, their life story, and their family situation. The CFI helped identify the most important problem and the treatment focus. One MD summed up the additional value of the CFI as follows: “Better understanding of the patient’s perception of own background and its role in the disorder.” Another MD stated: “[With the CFI,] it became evident that the patient is stuck in his own problematic situation and that he does not have any strategies to deal with it.” Information about social support and family situation were the most highlighted outcomes of the CFI. The MDs reported that they gained a more comprehensive understanding of the conflicts and relations in the patients’ family and close social network, which contributed to understanding the patient’s context. Some remarks were recurrent in relation to the family situation, for example: “The CFI gave me the opportunity to go more into depth with how the family ‘culture’ creates great conflicts between the patient and her family, and how it is a burden for the patient.” Some MDs found that the CFI helped identifying the most important problem and the treatment focus: “We [the MD and patient] pointed out a very concrete problem that the patient wanted to solve” – and another reported: “Her faith could possibly help her in the work with acceptance and understanding of her disorder.”

The patients’ reflexivity and understanding of the questions

Several of the CFI questions were described as hard to understand for some patients and demanded patients’ self-reflection in ways that were a barrier for conducting the CFI: “It became very obvious that the patient had a hard time following the interview cognitively. The questions were too difficult for him” and “The patient had difficulties answering/understanding the context and the words…” The MDs were trained to use probes (as suggested in the CFI) and to clarify meanings, but this did not seem to fully solve the problems with the patients’ understanding: “Several of the questions – even with elaboration – did not make sense to her.” This finding was independent of Danish proficiency and length of stay in Denmark (data not shown).

Cultural background of the patient

There were no specific questions regarding culture in the MDs’ questionnaire, but the MDs commented on the theme several times. Some MDs stated that the patient did not differ from the non-migrant population in Denmark and thus concluded that culture was not an issue in relation to the disorder: “The patient does not have a different cultural perception. Was raised by western-oriented parents! Came to Denmark [with her parents] early in life and does not need an interpreter.” A different position, held by some of the MDs, was that culture had a great impact on the understanding of the patients and their presentation of their problem: “There are cultural barriers that make it difficult to decode the meaning of what the patient says. At the same time, I have some doubt about how much the patient understands.” Finally, a third position taken by some MDs was that the cultural background of the patient was a key to understanding the person and the symptoms rather than a barrier for understanding:

What is significant from this patient’s culture? Masculinity. This is an issue of great importance for the patient and it is a stressor that he believes that his whole life can fall apart due to illness. The CFI has helped me understand the patient’s worries about and expectations for treatment.

In line with the quote above, another MD stated: “[The patient] has informed me that his culture and background taught him to be patient and to endure. He will not give up.”

Migrant patients

The results of the questionnaire on patient satisfaction and acceptability of the CFI are presented in Table 4. The overall impression of the CFI was positive for 93.0% of the patients (fair, good, or very good). The same percentage found that the MD showed understanding towards their cultural background. That said, 11.3% of the patients did not find that the CFI was very different from the questions the MD generally asks during other conversations.

Table 4.

Patients’ satisfaction with the Cultural Formulation Interview.

	Very badn (%)	Badn (%)	Fairn (%)	Goodn (%)	Very goodn (%)	Missingn (%)

What is your overall impression of the Cultural Formulation Interview?	0	1 (1.4)	5 (7.0)	31 (43.7)	30 (42.3)	4 (5.6)
	Not at alln (%)	To a lesser extent n (%)	To some extentn (%)	To a great extent n (%)	To a very great extent n (%)	Missingn (%)

Do you think that the medical doctor has shown understanding of your cultural background?	0	0	5 (7.0)	28 (39.4)	35 (49.3)	3 (4.2)
Do you think that the medical doctor asked about the most important things regarding your cultural background?	0	2 (2.8)	13 (18.3)	28 (39.4)	25 (35.2)	3 (4.2)
Were the questions very different from the questions the medical doctor generally asks during other sessions?	8 (11.3)	4 (5.6)	10 (14.0)	22 (31.0)	19 (26.8)	8 (11.3)
Do you think it is important that the medical doctor asks you these questions?	1 (1.4)	2 (2.8)	14 (19.7)	23 (32.4)	28 (39.4)	3 (4.2)
Do you think it is important that the medical doctor knows those things about you and your background which emerged during the conversation today?	3 (4.2)	2 (2.8)	10 (14.0)	22 (31.0)	29 (40.9)	5 (7.0)

Qualitative analysis of data from the patients identified 16 codes which were grouped into four main themes: i) positive experience of the CFI, ii) negative experience of the CFI, iii) tell my story, and iv) hope.

Positive experience of the CFI

The patients who gave positive feedback on the CFI commented on both the overall experience with the CFI (e.g., “The conversation was positive” and “Very useful”) and the formulation of the questions (“The questions were very tangible”). In the questionnaire, patients were asked to identify the best or most important CFI question. One response was “I don’t know because all questions were combined and interrelated,” whereas others gave concrete examples and highlighted questions focusing on “How can we help you with your problems?”; for example, CFI questions 14 and 16 (see Table 2 for the full list of questions).

Negative experience of the CFI

Negative feedback in the answers to the open-ended questions revolved around statements such as “The questions had nothing to do with me,” “It felt awkward,” and “Some of the questions were a bit strange.” Regarding which CFI questions were particularly difficult to answer, some patients stated that certain CFI questions were difficult to understand (e.g., “There were questions I didn’t understand”) and that the interview was difficult to remember, even though the questionnaire was filled in right after the interview: “[…] but I don’t remember it.”

Tell my story

The most consistent finding in the patients’ positive remarks when answering the open-ended questions was about the value and importance of telling their own story. Patients wrote feedback in line with the following quotes: “[The medical doctor] got more knowledge on my situation and my cultural background” and “The medical doctor understood the cause of my suffering. I feel very safe with her.”

Hope

To the question on how the CFI contributed to the patients’ attitude towards future mental health treatment, several patients expressed hope for the future and their future treatment. Some of the statements included: “I have noticed a positive effect already,” “If the medical doctor knows more about me, then she is better equipped to help me,” and “[The CFI] gave me much more positive outlook for the future.” In contrast, some felt less hopeful about their future following the CFI: “It was hard. I suddenly started thinking about stuff – like our poverty. That makes me sad.”

Discussion

The findings of this study on the clinical use of the CFI showed that, when added to a standard clinical assessment in mental health care, the CFI was useful to MDs for treatment planning and for exploring patients’ meaning-making concerning their cultural and social context, but that it was less useful for the diagnostic process. Patients reported a high level of overall satisfaction with the CFI and viewed it as a welcomed opportunity to tell their story.

This is the first study exploring the use of the CFI in Denmark and the first study of the CFI with a patient population primarily of Middle Eastern origin and with interpreting assistance. Findings from this study showed that the clinical utility of the CFI regarding the identification of symptoms and its usefulness in the diagnostic process were not considered high by the MDs, a finding which echoes the results of earlier studies using the OCF (Adeponle et al., 2012; Bäärnhielm et al., 2015). However, many MDs still reported that they had gained other types of information about the patient, which could be helpful in the further treatment process.

The patients’ mean duration of stay in Denmark was 18 years, which is very similar to other studies from CTP (Sonne et al., 2016; Carlsson et al., 2018). Thus, the patients’ cultural understandings of health and illness may have been influenced by the long stay in Denmark, which could explain why the MDs found the CFI less useful for the diagnostic process. However, length of stay in another country does not necessarily affect one’s explanatory models (Mattingly, 2008).

In Denmark, especially at CTP, standardized treatment packages are used. The standardization primarily concerns the scope of the treatment and, to a lesser extent, the content. This approach could be contradictory to the person-centered approach in the CFI, which strives to avoid stereotyping. Consequently, the results regarding usefulness for treatment planning are debatable because the standardized treatment leaves less room for the patient and the clinician to negotiate an individual treatment plan that is tailored to the preferences, values, and cultural background of the patient. Nevertheless, the findings from the qualitative results support the notion that the CFI is useful for individual adjustments in the treatment plan, even within rather standardized treatment courses.

The use of interpreting assistance poses well-known challenges, such as the risk of misunderstanding verbal and non-verbal communication and that of underestimating the influence of interpreting assistance on the treatment alliance (Bauer & Alegría, 2010). Therefore, it is a possibility that CFIs conducted with the assistance of an interpreter could contain less information than those conducted without such assistance, due to abbreviations and perhaps to less openness from the patient. Given that this study was conducted in real-life clinical settings and that the settings were not changed to fit a specific study design, it was not possible to extend any of the CFI sessions according to the need for interpreting assistance, meaning that the actual time spent on the CFI could be shorter in those sessions where interpreting assistance was used. However, the use of an interpreter did not affect the number of CFI questions asked.

The DSM-5 Handbook on the Cultural Formulation Interview highlights the importance of reflecting on issues related to cultural safety when implementing the CFI in clinical work, such as the fact that individuals who have experienced racism, discrimination, and marginalization can have mistrust towards institutions and their staff (Lewis-Fernández et al., 2016). This issue can result in difficulties in achieving effective assessments, including the CFI. Cultural safety has earlier been pointed out to be vital in obtaining cultural information in the clinical encounter (Kirmayer, 2012). With this in mind, the results of the MD questionnaire, which suggest that there was a limited gain of additional information about symptoms and diagnosis from the CFI, could be explained by lack of cultural safety among some migrant patients, affecting the amount of cultural information expressed during the CFI (Lewis-Fernández et al., 2016).

The MDs in this study were not paid separately to conduct the CFI, but carried out the study as part of their everyday clinical work. Busy clinicians may not use cultural assessments if the perceived cost in time outweighs the benefit (Aggarwal et al., 2013). The issue of time spent versus information gained seemed to be an issue for the MDs and might explain why data collection was difficult to manage. This study was conducted in a real-life clinical setting and therefore provides valuable information on the actual use of the CFI.

Limitations

Our study has some limitations. In 2016, two years after the initiation of this study, the DSM-5 Handbook on the Cultural Formulation Interview was published (Lewis-Fernández et al., 2016). There are points of discrepancy between how the developers of the instrument intended the CFI to be used and how it was applied in the present study. However, this study was initiated in concordance with the introduction text in DSM-5; to explore the additional value of the CFI, it was used after the first session. The results, especially on the usefulness of the CFI with regard to the patients’ symptoms and diagnoses, have clearly been affected by the study design, because this could have been exposed in the first session – to some extent at least. Given that CTP is a clinic specialized in transcultural psychiatry, it can be assumed that its MDs are trained and experienced in accordance with its transcultural assessments. This, and the fact that CTP was the main contributor to the data collection, might explain why MDs did not find the CFI very useful for identifying symptoms and diagnoses. The above-mentioned limitations might also explain why patients reported that the CFI questions did not differ much from the questions asked in the standard assessment. However, due to difficulties with data collection outside CTP, we did not have enough data to analyze the differences between tertiary and non-tertiary clinics. This would be an interesting area of further research.

The results indicate that the CFI is acceptable for psychiatric patients with interpreting assistance. However, the data were collected from the MDs between patient sessions and the shortage of time may have resulted in some of the answers being brief, which may not capture the full impact or nuances of CFI use. This study used self-report instead of more objective measurements, which could result in a social desirability bias. However, the MDs were asked about the CFI, not their own performance.

There has been growing discussion on the importance of training in the administration of the CFI. A recent study from Mexico suggests that training, especially about the concept of culture, is essential (Ramírez Stege & Yarris, 2017). Similarly, the results of the present study revealed that clinicians used a somewhat static concept of culture, whereas the CFI was based on a more dynamic concept of culture. If the clinicians are insufficiently trained in a dynamic concept of culture, then this will affect their ability to clarify and adjust questions to suit the individual patient. Uncertainty about the concept of culture could explain the finding that participants had difficulties in understanding the questions, as well as the finding that questions 5, 10, and 15 were asked less often than the other questions. Perhaps the MDs were not aware of how questions 5 and 15 could indirectly reveal the cultural background of the patient, and perhaps they lacked information to adjust and clarify question 10. The 12 MDs counted multiple times based on their numbers of conducted CFIs with patients. However, since they did not conduct the CFI the exact same number of times and their average ratings were not compared, this could potentially have led to bias.

A methodological strength of our study is the mix of quantitative and qualitative data and the real-life clinical conditions under which the data were collected, as opposed to a setting changed to fit a specific study design. This resulted in a nuanced description of the clinical usefulness of the CFI. This study also included an aspect of the potential use of the CFI in somatic health care. However, because we had access to few participants from IMK, these results are not generalizable. Further research in this area is recommended.

Conclusion

The findings of this study suggest that the CFI is useful to experienced MDs working in a transcultural mental health clinic for treatment planning purposes but of less use in the diagnostic process. Furthermore, the CFI was found to be a useful instrument for exploring the cultural and social context of the patients’ mental health problems. The patients viewed the CFI as a welcome opportunity to tell their story, and the findings show that the CFI is also acceptable for psychiatric patients of primarily Middle Eastern origin and when using interpreting assistance. In conclusion, based on the findings of this study, use of the CFI is recommended to clinicians for treatment planning purposes, as it can give a better understanding of the mental health problems of the individual patient.

Footnotes

Acknowledgements

The authors wish to thank all the patients and clinical staff at the Competence Centre for Transcultural Psychiatry, Birgitte Zwicky-Hauschild and Mathilde Pihl Badse at the Section of Immigrant Medicine, Department of Infectious Diseases, University Hospital Hvidovre, and Lene Sandø Ebbe at the Outpatient Clinic Ballerup, Mental Health Centre Ballerup for their collaboration, data collection, and enthusiasm, and Sarah Musoni for help with proofreading. We would also like to thank Professor Roberto Lewis-Fernández, Marianne Østerskov, and Maj Philipson for sharing their vast knowledge and clinical experience, and for valuable discussions on the use of the CFI.

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 author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The present study was funded by TrygFonden (grant number 120354) and the Jascha Foundation (grant number 6209).

Signe Skammeritz, MD, PhD, is about to complete her specialization in psychiatry. She has research affiliations with the Competence Centre for Transcultural Psychiatry, Denmark. Her research focuses on clinical and epidemiological research in transcultural psychiatry.

Laura Glahder Lindberg, MSc Public Health, is a PhD student at the Competence Centre for Transcultural Psychiatry and the University of Copenhagen, Denmark. Her research focuses on person-centered care and mental health care for underserved populations.

Erik Lykke Mortensen is a psychologist by training and Professor of Medical Psychology at the University of Copenhagen, Denmark. He has published in many fields of relevance to medical psychology, including both clinical and epidemiological studies. His primary contributions have been studies of the influence of prenatal and early postnatal factors on mental and physical development and studies of factors influencing age-related cognitive decline.

Marie Norredam, MD, DMSc, is a Professor at the Danish Research Centre for Migration, Ethnicity and Health at the Department of Public Health of the University of Copenhagen, Denmark. She has research affiliations with Harvard Medical School, Boston School of Public Health, and Oxford Refugee Studies Centre. Further, she is a co-founder and chair of the Danish Society for Immigrant Medicine and member of several steering committees related to migrants’ health. Her research especially concerns migrants’ formal and informal barriers to accessing to health care, including the health reception of migrants, as well as disease patterns and risk factors related to migration processes. Her research has a special focus on vulnerable migrants, including children, undocumented migrants, asylum seekers, and refugee populations.

Jessica Carlsson, MD, PhD, is the Research Director of the Competence Centre for Transcultural Psychiatry and Associate Professor in Psychiatry at the Department of Clinical Medicine of the University of Copenhagen, Denmark. Her primary research areas are clinical studies of trauma-affected refugees and transcultural psychiatry.

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