The Cultural Formulation Interview: Progress to date and future directions

Introduction

Since 2009, the last time an issue of Transcultural Psychiatry focused on the Cultural Formulation Interview (CFI), a lot has happened (Lewis-Fernández, 2009). A large international field trial was conducted and its results were published (Lewis-Fernández et al., 2017), the final version of the CFI appeared in DSM-5 in 2013 with both patient and key informant versions (American Psychiatric Association, 2013), and 12 supplementary modules covering specific topics and populations were prepared along with guidance for their use (Lewis-Fernández, Aggarwal, Hinton, Hinton, & Kirmayer, 2016). In fact, the American Psychiatric Association (APA) has made the CFI, its supplementary modules, and videos from the DSM-5 Handbook on the Cultural Formulation Interview available free of cost across various websites to assist with dissemination. ¹

Mental health practitioners of all disciplines are gradually becoming aware of the CFI, and the pace of research on its use has stepped up (Aggarwal, Jarvis, Gómez-Carrillo, Kirmayer, & Lewis-Fernández, 2020; Jarvis, Kirmayer, Gómez-Carrillo, Aggarwal, & Lewis-Fernández, 2020). Many clinical training programs have incorporated the CFI in teaching cultural competence (e.g., Díaz, Armah, Linse, Fiskin, Jordan, & Hafler, 2016; Mills et al., 2016) and the CFI is often included in grant rounds and continuing education programs for practicing clinicians. This level of acceptance likely has occurred because the CFI meets a need in the field for a brief, skills-based, teachable method of carrying out cultural assessment with individual patients (Edwards, Burkard, Adams, & Newcomb, 2017). Evidence so far holds promise for the wide applicability of the CFI; for example, several independent studies have shown that clinicians, patients, and family members find it feasible and acceptable, and that they expect it would be useful to care provision (Lewis-Fernández et al., 2017; Paralikar et al., 2015; Skammeritz, Lindberg, Mortensen, Norredam & Carlsson, 2020; Wallin, Dahlin, Nevonen, & Bäärnhielm, 2020). Despite this progress, however, much remains to be done. This issue of Transcultural Psychiatry collects recent submissions relevant to the CFI and points to areas for further work. In this editorial introduction, we highlight three key areas raised by the studies in this issue and by previous research on the CFI: (1) transforming psychiatric assessment models; (2) developing implementation and scale-up strategies; and (3) refining the CFI protocol based on further research and clinical experience.

Disrupting and transforming current psychiatric assessment models

The first area raised by the contributions to this issue involves the extent to which the CFI is able to disrupt, and ultimately transform, mental health assessment as usually practiced, at least in psychiatry. A key goal of the CFI is to place the experience of the patient front and center, allowing the clinician to appreciate the personal, interpersonal, and larger social contexts in which the problem, its interpretation, and clinical presentation emerge. Too often, these elements are not highlighted in initial assessments, which in psychiatry tend to focus on diagnosis based on signs and symptoms. To elicit subjective and contextual information from patients and their companions, the CFI engages them in a guided, open-ended conversation that covers a range of topics in a parsimonious but connected way. The interview process aims to allow a narrative flow, in which the person reveals aspects of their health and illness experience and makes new connections regarding their situation. In other words, the process of conducting the CFI is as important as the content elicited. Research with the CFI has shown that patients value the ability of the clinician to express caring and concern through the CFI questions, which can enhance rapport and communication (Aggarwal, DeSilva, Nicasio, Boiler, & Lewis-Fernández, 2015; Paralikar, Deshmukh, & Weiss, 2020). By giving explicit attention to patients’ experience of suffering, and eliciting relevant aspects of their identity, understandings of illness, and current predicament, the use of the CFI conveys the clinician’s interest in the patient as a person. This interest, along with expressions of empathy and solidarity, can help the provider build an effective clinical alliance with the patient, a key element of helping and healing.

Although the order of questions in the CFI is deliberately designed to follow from an initial focus on clinical symptoms and concerns to broader issues of identity, contexts, and needs, it can be modified to fit particular situations. When given adequate time, the CFI allows patients to co-construct an illness narrative that begins to make sense of their predicament and points to key issues and areas for further exploration. This narrative-building process is one reason why many of the CFI developers recommend conducting the CFI as a whole rather than interspersing individual CFI questions into the usual assessment interview. Moreover, it underscores the need to treat the CFI questions as elicitors of narration rather than items on a checklist, and—although questions to clarify details or meaning are always relevant—to avoid diverting the overall flow of this narrative process to pursue aspects that seem important to the provider because they point to familiar signs and symptoms of disorder or because they fulfill a professional requirement such as conducting a risk assessment (Aggarwal et al., 2014). This is also why we recommend that, when possible, the CFI be the first component of the evaluation, to highlight the centrality of the patient’s perspective, allow this perspective to guide the rest of the interview, and signal to patients the value placed on their views. However, it is also clear that a rigid insistence on protocol or standardization can interfere with the flexibility needed to establish and maintain rapport and support the narrative-building process, and that probes, alternative transitions, and more in-depth explorations are often needed (Jarvis et al., 2020; La Roche & Bloom, 2020; Rousseau, Johnson-Lafleur, Papazian-Zohrabian, & Measham, 2020). The effective use of the CFI depends on basic interviewing skills and extends to the art of conducting a person-centered, culturally informed evaluation, which involves flexible responses to the specifics of the person, problem, setting, and other elements of the interview, which are shaped by the identity and social position of both patient and clinician—all of which must be considered during CFI training and implementation (Aggarwal et al., 2020; Lewis-Fernández et al., 2016).

The articles in this issue explore various modes of integrating the CFI into clinical work. Aggarwal and colleagues (2020) discuss the values of both standardization and flexibility. In research, standardization enables the study of mechanisms of action and identifying essential elements by assessing for the effect of fidelity in administering the CFI as a reproducible intervention. This may facilitate the development of versions of the CFI that can be used like a cultural “review of systems” to guide more focused inquiry in settings with strict time constraints. Of course, standardization also can simplify training and implementation. Flexibility, on the other hand, is needed to address diverse needs across settings and the range of interview goals, various communication practices among patients and families, and different disciplinary approaches to clinical work. For example, La Roche and Bloom (2020) emphasize the difficulties of conducting the core CFI with children under the age of 11, who have not reached the formal operational stage. For this age group, they suggest expanding or transforming the CFI to include the usual techniques of child-focused work, such as playing, drawing/building/sculpting, acting, story-telling, and other expressive modalities, coupled with verbal description. They suggest the formal mental status exam can be performed after Question 3 of the core CFI on the most troubling aspect of the presenting problem.

Work on cultural formulation in other settings also emphasizes the important of flexibility, with lessons for the use of the CFI (Mezzich, Caracci, Fabrega, & Kirmayer, 2009). In their contribution to this issue, Rousseau and colleagues (2020) focus on the role of interdisciplinary case discussion seminars (ICDSs) as a way to train students and practicing providers in the CFI. They advocate adapting the CFI to specific patients and situations as a necessary component of cultural assessments, using “tangential” or “indirect” questioning (Ghane, Kolk, & Emmelkamp, 2012) to purposefully deviate from a “direct linear administration” of the CFI, particularly when communication is limited by self-silencing and social desirability (Rousseau et al., 2020, p. XX). A key value of ICDSs lies in the ability to train providers in the art of integrating the CFI into a living assessment tailored to each person and situation. The qualitative data obtained by Wallin and colleagues (2020) and Skammeritz and co-workers (2020) also reveal clinicians’ need for flexibility in wording and time allocation of various CFI components—aspects of implementation contemplated since the initial development of the CFI (Lewis-Fernández et al., 2016).

The tension between standardization and flexibility is one of the key areas in need of further CFI research. The full range of solutions to the tension will likely only come from analysis of multiple real-world applications and testing of implementation approaches. What is clear is that conducting the CFI mechanically, as a kind of checklist, does not accord with its narrative-focused approach (Kleinman, 2016). Checklists are useful to enhance quality of mental health care (Carlat, 1998) but their use must be balanced with the elicitation of patients’ stories and the fostering of contextual thinking, which are main goals of the CFI.

Identifying effective dissemination and implementation strategies

A second major area raised by research on the CFI, including the papers in this issue, involves identifying the best dissemination and implementation strategies to encourage its adoption and sustainability in varied practice settings. The CFI was designed to be a simple tool for providers to use in everyday clinical work. The Outline for Cultural Formulation (OCF), introduced in DSM-IV, provided an outline for organizing relevant information in cultural clinical assessment. However, the OCF had limited application, in part because of uncertainty about how to collect the kind of information it listed (Kirmayer, Thombs, Jurcik, Jarvis, & Guzder, 2008). The explicit aim of the CFI was to operationalize cultural assessment for clinical work in real-world settings, by prioritizing brevity and fit with existing systems of care. The CFI opens up a broad consideration of patients’ experience and social context. In-depth exploration of this takes time and will generally be part of more extended evaluations and ongoing care. However, to be used widely in mental health care, the CFI needs to fit the constraints of current clinical practice, which offers a narrow window of opportunity.

How can the fit of the CFI be optimized in different settings? For example, how can the CFI best fit into team-based care, where one provider may conduct the CFI but other providers make diagnostic or treatment decisions? This is a key question in emergency rooms, inpatient units, consultation-liaison teams, and day treatment settings where a patient may come into contact with multiple providers. In the setting studied by Wallin and colleagues (2020), one clinician typically conducts the CFI while another determines the diagnosis. Their qualitative data from clinicians suggest that strategies must be devised to enhance sharing of CFI-obtained information across clinical team members to foster its inclusion in all aspects of care. In many high-resource settings, incorporation of the CFI into electronic health records (EHR) is a possible solution, especially if this can be organized in a way that guides overall case formulation and treatment planning. Several formats are in development, including the one suggested by Paralikar and colleagues (2020) based on the five domains of a revised OCF. However, the information documented in records is often limited and cannot capture the rich discussions and multiple perspectives presented in clinical team rounds and interdisciplinary case conferences. The incorporation of such information in an EHR may also prioritize the information-gathering purpose of the CFI, which often matters more to clinicians than to patients, who typically see the CFI as a conversation that helps the clinician understand and empathize with their experience (Aggarwal et al., 2015; Aggarwal, Lam, Díaz, Cruz, & Lewis-Fernández, in press). A patient-centered approach to incorporating CFI information within the EHR can also make explicit what matters most to patients during the interaction.

At the same time, incorporation of the CFI within an EHR needs to be user-friendly. We have seen the core CFI reproduced verbatim with text boxes below each question so that providers can record answers. Without sufficient training, time, or organizational incentives, providers may find this format burdensome. In such instances, providers may input terse responses such as “not relevant,” “patient too sick,” “not available,” or leave the text boxes blank. To prevent the CFI from becoming an organizational requirement that is divorced from therapeutic relevance, empirical work is needed to clarify how organizations develop EHRs to record information from the CFI, ideally with provider feedback to increase buy-in, and the extent to which providers document such information and make use of it in subsequent care.

Many other implementation questions remain. How can the information from the CFI be incorporated into treatment plans? López et al. (2020) provide one of the first empirically based suggestions on how to carry out this integration. Their Shifting Cultural Lenses model systematizes the application of cultural assessment information into psychotherapy in three steps: (1) eliciting the person’s cultural views of the problem or predicament, (2) communicating the therapist’s own views, and (3) developing a shared narrative by integrating the person’s views, asking for their buy-in to the therapist’s views, and negotiating different options. Further work is needed to apply this model to diverse settings, problems, patients, disciplines, and treatment modalities.

Training is another key issue for implementation. What are the most effective and efficient forms of training for busy providers? A simple training module was developed for clinicians involved in the DSM-5 CFI field trial (Aggarwal et al., 2016), and subsequent studies have focused on psychiatry residents and fellows (e.g., Díaz et al., 2016; Mills et al., 2016; Padilla, Lewis-Fernández, & Benjamin, 2016). How can the methods they describe (or others) be applied to in-service instruction? While ICDSs are a possibility, they require a 3-hour time commitment from the service. What other alternatives exist? The first authors have developed an online training module for providers and university-based training programs and some data have been reported on its uptake in the public mental health system in New York State (Aggarwal et al., 2018). ² How could use of this online module fit into a comprehensive training program? For example, what are the relative contributions to CFI mastery of initial training, ongoing practice, and/or regular supervision? Research in the DSM-5 field trial in a New York public outpatient psychiatric clinic and subsequent work in a U.S. Veterans’ Administration hospital suggest that adequate fidelity in CFI administration can be achieved after a single in-person training session and some practice (Aggarwal et al., 2014; Muralidharan et al., 2017). Would use of the online module by itself achieve this goal? Are these gains sustainable over time after a single training session or would booster sessions be needed? If booster sessions are needed, with what frequency and format? Such questions assume increased importance in the U.S., because some jurisdictions now mandate cultural competence training as a precondition to renew practice licenses for various providers. Similar requirements instituted internationally could drive uptake of the CFI as a useful component of broader cultural competence skills (Kirmayer et al., 2020).

At what point in the process of care should the CFI be used: at admission, when transferring from one level of care to another, at discharge, or whenever there is patient–provider disagreement (even later in long-term clinical care)? The limited research to date suggests that the answer depends on the healthcare system and the clinical characteristics of the patients. Clinicians may benefit from CFI information at any time point in care, as long as the patient is clinically stable and staff recognize the CFI’s value and participate in the best way to integrate it (Aggarwal et al., in press). How can the CFI incorporate the input of interpreters and culture brokers, who are often indispensable in work with immigrants and refugees? In this issue, the work of Skammeritz and colleagues and Wallin and co-workers suggests that the CFI is compatible with interpreter-mediated care, though extra time must be allocated for the interview. The Cultural Consultation Service in Montreal routinely works with interpreters in conducting more intensive interviews that include the areas addressed by the CFI and has provided guidance for the role of interpreters and cultural brokers in such assessments (Leanza, Miklavcic, Boivin, & Rosenberg, 2014; Miklavcic & Leblanc, 2014). ICDSs routinely combine the input of culture brokers with discussion of CFI material (Rousseau et al., 2020), but no studies to date have specifically evaluated the inclusion of interpreters and culture brokers in the implementation of the CFI. ³ If more in-depth cultural assessment is needed, what is the role of alternative cultural assessments? Can the core CFI be used as a screening evaluation, to be expanded not only by employing the CFI supplementary modules, but additionally or alternatively by longer cultural assessments, such as the Brief Cultural Interview (Groen, Richters, Laban, & Devillé, 2017), the Cultural Interview (Rohlof, Groen, van Dijk, & Knipscheer, 2017), the Bloomsbury Cultural Formulation Interview (Jadhav, 2013), ⁴ the McGill Illness Narrative Interview (Groleau, Young, & Kirmayer, 2006), or other approaches (Edwards et al., 2017)?

Improving the CFI: Evidence and practice-based approaches

The third major area for further research and clinical work addressed by the articles in this issue is how to improve the CFI, as well as the Outline for Cultural Formulation on which it is based. Two areas have consistently been raised in recent studies and critiques of the CFI (Jarvis et al., 2020): how best to assess cultural identity and how to incorporate greater attention to social structural and institutional dimensions relevant to assessment (e.g., Bäärnhielm et al., 2016; Ramírez-Stege & Yarris, 2017).

Cultural identity remains a difficult concept to explain briefly during CFI administration, especially because the CFI definition of culture incorporates many domains of identity that are highly context-specific (Aggarwal, 2012). The CFI asks the patient to describe aspects of their identity relevant to their illness experience and clinical care. Responding to this requires a high degree of self-reflexivity on the part of the patient. Even with that, there may be no simple answer because of the complexity of identity or the nature of the clinical setting and encounter.

Identity is complex, multi-stranded, involving multiple groups, roles, and affiliations—which are chosen or imposed by others to varying degrees—and is embedded in personal and life narratives, embodied in habitus, and enacted in voice, style, and social positioning. The aspects that are salient in clinical assessment may shift with the facet of the health condition or life situation under discussion as well as with patients’ perceptions of the identity of the interviewer, the institution, and the consequent safety of the clinical setting. Based on the DSM-5 field trial, efforts were made to clarify the identity questions to convey their broad ambit and encourage patients to offer whatever facts they thought relevant. Despite these modifications, questions 8–10 of the core CFI on cultural identity remain difficult to understand for some patients and providers (Skammeritz et al., 2020; Wallin et al., 2020). Additional work may be required to clarify them. This work needs to consider the varied meanings of identity in context and appreciate patient self-identification as a more-or-less strategic act of social positioning with implications for clinical care that go well beyond the initial assessment.

Another area for improvement involves how to ensure the CFI captures key aspects of the social context and lifeworld, especially those related to crucial social determinants of health. The CFI provides an opportunity for patients to identify social stressors and supports as well as issues related to their social positioning, but does not systematically canvas the range of social structural determinants of health explored in research. Systemic, institutionalized political and economic dimensions of social life include differential access to resources and opportunities (e.g., education, housing) that have a substantial impact on health disparities. Proponents of clinical structural competence argue these issues may be more important for clinical assessment and intervention than cultural knowledge and identity per se (Holmes et al., 2020; Metzl & Hansen, 2014, 2018). But as with cultural assessments, studies of the implementation and impact of structural competence on clinical practice remain limited. While individuals are not always aware of all the social structural factors that impinge on their health and well-being, they can offer crucial information that points to these issues. Indeed, the patient’s level of awareness of and response to such structural issues is an important aspect of their health status, in its own right.

The CFI includes open-ended questions about stressors and supports as well as barriers to care. Could more information on social structural issues be elicited by revising the guidelines for interviewers regarding these items, or are new open-ended questions needed that focus explicitly on structural factors? Within the open-ended, person-centered framework of the CFI, how can patients be encouraged to think about these broader contextual factors in a way that does not prioritize the interviewer’s concerns over theirs, but rather that taps their lived experience in ways that can complement “objective” social indicators like income or social status? Paralikar and colleagues (2020) suggest grouping these topics into a new OCF domain on Social, cultural, political, and economic contexts and possibly expanding the CFI questions in this area. This is consistent with recent efforts to elaborate notions of structural competence (Metzl & Hansen, 2014). However, one dilemma posed by this shift is that essential information on social structure and adversity may not be available by interviewing patients. Social adversity is built into the fabric of everyday life in ways that may be entirely taken for granted or invisible. Uncovering this structural violence may require social data and analysis that go well beyond what patients can report or what providers may believe to be within the scope of their clinical practice.

Paralikar and colleagues (2020) also recommend reorganizing the OCF to better match the CFI structure, for example by consolidating the description of items related to illness explanatory models and key social relationships into newly organized OCF domains. One of their goals is to clarify the intent of the CFI by keying its content more explicitly to an expanded OCF. This is important because, while the CFI offers a way to collect information, cultural formulation depends on organizing the information in meaningful ways that bring out systemic relationships. The OCF is one basic structure for this but it is essentially a list of topics or dimensions. To guide cultural formulation, other frameworks are needed, based on causal or process models, to help link the social and cultural information collected through the CFI to specific neurobiological, psychological, and social mechanisms of psychopathology, adaptation, and recovery (Kirmayer, 2016).

To choose among these recommendations for refining the CFI, and generate additional ideas, the field needs more empirical research. It is likely that revisions to the protocol will depend on specific contexts and goals of CFI administration. For example, several authors have called for shortening the CFI for use in low-resource or high-volume settings (e.g., Jarvis et al., 2020; Paralikar et al., 2015). The pruning choices may depend on the interview goal, so empirical studies with a range of outcomes are needed to guide this process. Multiple goals are possible, raising the broader question of what aspects of care the CFI is most useful for: diagnostic accuracy, clinical rapport and alliance-building, enhanced communication, patient engagement and participation in care, treatment response? Work to date suggests the CFI and OCF may be relevant to all of these to varying degrees in diverse contexts (Adeponle, Thombs, Groleau, Jarvis, & Kirmayer, 2012; Aggarwal et al., 2015; Kirmayer, Guzder, & Rousseau, 2014; Zandi, Havenaar, Laan, Kahn, & van den Brink, 2011). This refinement process is also relevant to the goal of widespread implementation. To reach a tipping point where the CFI becomes mainstream practice, cost-benefit data on the impact of current or new versions will be essential to show that the additional time and effort needed to conduct the CFI results in significant improvements in quality of care and outcomes.

Finally, how can the focus of the CFI be expanded to include other specific topics and patient groups? One approach would be to develop additional supplementary modules that branch off from CFI questions to explore issues in more depth (Lewis-Fernández et al., 2016). A grief-focused module has already been published (Smid, Groen, de la Rie, Kooper, & Boelen, 2018) and a revision of the CFI for use with military personnel is being developed by Eric Meyer and colleagues (Hann et al., 2017). How do we decide when a supplementary module for a specific mental health issue or group may be needed, as opposed to expanding the guidelines of existing CFI components to address the relevant issues? What are the implementation repercussions of multiple versions and supplements of the CFI? Lastly, are there situations where the CFI is not recommended? Clinical experience tends to argue against using the CFI with acutely psychotic individuals (Aggarwal et al., in press; Paralikar et al., 2015), though those who are less acutely psychotic may benefit (Muralidharan et al., 2017). More empirical data are needed, including on the impact on CFI performance of patient levels of cognitive impairment or aggressiveness.

For some applications, the whole protocol may need to be rethought. The need for new methods for use with young children has already been mentioned (La Roche & Bloom, 2020). Similarly, applying the CFI to assess families may also require rethinking the process (e.g., Aggarwal et al., 2020). Family systems are central to cultural assessment, and the locus of problems and solutions often resides in family structure and interactional process (Guzder, 2014). Clarifying this requires engaging the family as a whole in the interview, not simply as collateral informants (as elicited by the Informant version of the CFI), or individuals with their own concerns, but as embedded in a dynamic system. A family approach is particularly important in cultures where families and even larger social networks are central to identity, as noted in this issue by Langa and Gone (2020) in their exploration of PTSD and major depressive disorder in sociocentric cultural contexts. Can a version of the CFI be developed to guide family assessment by decentering from the identified patient and focusing on the family context as the potential ground of psychological distress and healing? If so, how would the clinician capture the complexity of the varied perspectives within the family (Jarvis et al., 2020)? Although engagement with the family is often essential in cultural psychiatry, it is not clear if the CFI can facilitate this process in the same way that it appears to work in individual interviews. Families may appreciate the effort to understand their culturally based perspectives, values, and concerns but the process of inquiry may also reveal unresolved conflicts between family members or across generations that must be approached strategically to maintain engagement (Guzder, Santhanam, & Rousseau, 2014). Culturally oriented family assessment has its own literature which can inform efforts to develop a CFI-related protocol to capture multiple perspectives and system dynamics (Okazaki, Ling, Wong, & Tu, 2017; Walsh, 2016).

Conclusion

The articles collected in this issue of Transcultural Psychiatry advance the work on the CFI and provide evidence for its utility in various settings. We have made significant progress since 2009, but much work remains to be done both to put the CFI on a firm empirical footing and to realize its potential to transform care by applying patient-centered, culturally informed thinking to assessment, case formulation, and treatment. Most research on the CFI since the field trial has been conducted in high-income countries, especially with migrants from low-income regions. This work should be expanded to clinical settings in low- and middle-income countries, to validate the usefulness of the CFI in those settings and to guide implementation strategies that fit their high-volume, resource-poor environments. Having a simple, practical tool should make it easier for clinicians everywhere to add systematic attention to culture and context to their assessment. But culture has myriad and changing meanings—as the current moment of global isolation in response to the COVID-19 pandemic dramatically illustrates. The CFI, of necessity, will need to evolve in response to the changing configurations of cultures, social worlds, and mental health care.