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This chapter discusses potential uses of the DSM-5 Cultural Formulation Interview (CFI) within intercultural psychotherapy. We present this chapter in three sections: (1) challenges that may emerge within the cross-cultural therapeutic encounter, (2) recommendations that have been offered to overcome such challenges, and (3) the extent to which the clinician’s application of the CFI responds to such recommendations. Our goal is not to provide an overview of the CFI or its general pertinence to psychotherapy, which we have provided elsewhere [1, 2]. Instead, we situate this work within the scholarship on intercultural psychotherapy for practitioners trained in this orientation. We restrict ourselves to a critical review of English-language articles, while acknowledging that intercultural psychotherapy has elicited scholarship in multiple languages.

The Challenges of Intercultural Psychotherapy

We begin with an overview of intercultural psychotherapy. In a seminal article from over four decades ago, Jing Hsu and Wen-Shing Tseng define intercultural psychotherapy as “psychotherapy in which the therapist and the patient have different cultural backgrounds so that interaction of the cultural components is involved in addition to the ordinary process of psychotherapy” ([3], p. 700). Although they do not define culture, they view it as an individualised process of meaning-making rather than a set of “dos and don’ts” for social groups convened around demographic characteristics such as race, religion, ethnicity, language, or country of origin: “Every person has his own unique cultural background, associated with his own personal experience, family situation, and social environment, which constantly affects the process of ordinary psychotherapy” ([3], p. 700). Hsu and Tseng list critical factors that reflect the influence of culture during psychotherapy, which are presented in Table 4.1.

Table 4.1 The influence of culture within intercultural psychotherapy
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Apart from transference and countertransference, the factors in Table 4.1 refer to the effect of culture on the ideational aspects of psychotherapy, i.e. the process of cognition-based information exchange between patients and clinicians. This exchange includes delineating the boundaries between normal and abnormal behaviours for diagnostic purposes, clarifying the patient’s communication styles, negotiating treatment goals, and integrating cultural information throughout all aspects of care. Over time, other therapists have identified culture’s influence on the emotional aspects of psychotherapy. For example, cultural differences can catalyse counter-transferential reactions by preventing the clinician from understanding the patient’s internal frame of reference, exhibiting non-judgmental respect, and participating within the relationship in a fully engaged manner [4]. Patients may also stop the therapeutic relationship from deepening or by resisting the clinician’s interpretations if they perceive that the clinician does not understand them [5]. Indeed, transferential and counter-transferential reactions can span a whole range of emotions—even when patients and clinicians share similar cultural backgrounds—such as overfriendliness, irrelevant interest in cultural differences, denial of such differences, ambivalence about the relationship, and sometimes outright hostility [6].

In fact, cultural psychiatrists have pointed out how culture constructs fundamental forms of knowledge and practice that are too often taken for granted in psychotherapy. Culture shapes the sociolinguistic codes through which patients decide which circumstances are acceptable—when, where, how, for what purposes, and to whom—for narrating their experiences of wellness and distress [7]. For instance, secular Euro-American models of talk therapy assume that all individuals act to advance self-interest and feel comfortable with articulating their psychological conflicts, which people from collectivistic backgrounds or unaccustomed to speaking with strangers may not share [8]. Through models of health and illness that are exchanged with families and friends, culture moulds patient perceptions of acceptable treatments such as which modalities are judged to be helpful, which costs or side effects are worth risking, and how long treatment should last [9]. Finally, culture constrains the knowledge and practice through which clinicians interpret patient narratives, such as a clinical formulation based on psychodynamic or cognitive-behavioural models of the mind [10]. This perspective affirms Hsu and Tseng’s assertion that all clinicians must customise psychotherapies based on the unique cultural characteristics of individual patients.

Recommendations to Overcome Clinical Barriers in Intercultural Psychiatry

In the 1970s and 1980s, clinicians created guidelines for specific racial and ethnic groups and encouraged patients and clinicians to be matched accordingly, in response to the US civil rights movement and immigration reforms; by the 1990s, a new generation of clinicians began to offer practice recommendations for intercultural psychotherapists irrespective of whether the patients or clinicians belonged to a particular race or ethnicity [11]. Table 4.2 lists recommended practices which have achieved widespread acceptance.

Table 4.2 Recommendations for successful intercultural psychotherapy
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In addition, intercultural psychotherapists have recommended an ethnographic approach to conducting interviews. For example, Karen Seeley has identified anthropological variables such as “selfhood, human development, cognition, emotion, language, and relationship as culturally shaped and as cross-culturally variable” which can be helpful to explore ([13], p. 123). She calls on psychotherapists to act as clinical ethnographers in their therapeutic work: “Clinically adapted ethnographic inquiry provides psychotherapists with tools for exploring the indigenous categories and conceptions of mind, self, relationship, and disorder that structure their clients’ experiences. By doing so it offers clear alternatives not only to treatment approaches based on cultural knowledge, but also the presumptive Western notions of disorder that are embedded in standard therapeutic procedures and diagnostic categories” ([13], p. 124). To clinical ethnography, Adil Qureshi adds clinical hermeneutics which assumes that patients and clinicians jointly construct clinical meanings: “Rather than simply consisting of an exchange of information, the relationship and interaction between the participants is key in the interpretive process. The disposition of the participants towards each other impacts not only the manner in which information will be received but also affects the way it is sent” ([14], p. 121). He rejects the idea that clinical meanings are singly produced either by patients or clinicians: “The client’s ‘reality’ is not independent and transcendent; rather, it is affected by the preoccupations of the client and the interaction with the counselor, precisely because selfhood is understood to be constituted dialogically” ([14], p. 124). From this perspective, clinicians who follow broad recommendations for patients based on group-level demographic traits such as race, ethnicity, or religion violate a critical principle of co-constructing meaning: “Prescriptions for multicultural therapeutic work are problematic. Privileging a particular method as the means for effective therapy implies that one can know a client in advance; it ignores our socio-historical situatedness and dialogical interaction” ([14], pp. 125–126). Recommendations for clinical ethnography and hermeneutics also have an independent lineage within cultural psychiatry and psychiatric anthropology, as this quote from Byron Good and colleagues exemplifies: “A hermeneutic analysis of clinical phenomena focuses attention on the role of deeply embedded personal texts in the interpretive process. Interpretation is not limited to the cognitive manipulation of clinical models, because the symbols, models and images of an individual’s therapeutic discourse have deeply rooted and unexamined personal meanings and are associated with powerful affects” ([15], p. 283). One pivotal insight unites these disparate authors: clinicians must work with culture to uncover how patients interpret themselves, their experiences, and the world around them. As noted earlier, this jointly developed interpretation should evoke both cognitions and affects to enable the desired behaviour change.

The DSM-5 Cultural Formulation Interview and Intercultural Psychotherapy

We believe that the CFI responds to many recommendations from intercultural psychotherapists. The CFI refers to a collection of three types of semi-structured interviews that facilitate a pragmatic cultural assessment, either by interviewing patients or their close associates such as family or friends. These three types of interviews are: a 16-item questionnaire that is increasingly becoming known as the “core” standard within the CFI practice community; a CFI-Informant Version for obtaining collateral information from caregivers; and 12 supplementary modules to inquire about topics introduced in the core CFI and to assess specific populations (e.g., immigrants and refugees).

The DSM-5 Cross-Cultural Issues Subgroup followed a rigorous methodology in developing the CFI from the DSM-IV Outline for Cultural Formulation by: (1) conducting a comprehensive literature review of 140 publications in seven languages, (2) field testing a preliminary version of the core CFI with 321 patients, 75 clinicians, and 86 family members in six countries, and (3) revising this preliminary version to form the final version included in DSM-5 based on patient, clinician, and family member feedback [16]. This design responds to calls within the literature on developing psychosocial (i.e., talk-based) interventions that need clinical trials to test mechanisms of action [17] but must also enroll patients from diverse diagnostic [18] and demographic backgrounds [19] for broad applicability. For several months in 2011 and again in 2012, a draft of the CFI was also posted on the DSM-5 website of the American Psychiatric Association (APA) to elicit comments from the public in recognition that cultural assessments have sparked interest among multiple stakeholders such as patients, clinicians, and clinic administrators [20].

The field trial utilised a variety of qualitative and quantitative measures with patients, clinicians, and family members to understand the CFI’s effects on the therapeutic relationship at the process level. Qualitative research can help to develop culturally competent, evidence-based practices by recognising that study participants are experts on their lives and experiences, allowing researchers to isolate variables of interest [21]. For example, we learned through qualitative debriefing interviews after CFI sessions that patients regarded the CFI as improving clinical rapport through open-ended, person-centred, and non-judgmental questions whereas clinicians valued the CFI’s elicitation of patient perspectives on illness and treatment [22].

The CFI has been designed for use with any patient in any mental health setting. It may improve the therapeutic alliance and the case formulation if it is used as intended during the initial session with new patients before proceeding to a diagnostic interview [23], regardless of the psychotherapist’s training in a theoretical orientation. On average, the CFI takes about 20 min to complete [16]. Hence, a clinician could set the therapeutic frame using a culturally informed approach. However, DSM-5 specifies that the CFI may be helpful at any point in the treatment, not just during the initial session. Use of the CFI may be most needed when there is difficulty in assessment owing to differences in the cultural, religious, or socioeconomic backgrounds of the clinician and patient; when there is uncertainty about the fit between culturally distinctive symptoms and official diagnostic criteria; when it is difficult to judge illness severity or impairment; when patients and clinicians disagree on treatment planning; or in instances when patients do not adhere to treatments or attend appointments [23].

The Core and Informant versions of the CFI include instructions to clinicians on the left side and question on the right so that clinicians know what kind of information is sought and how it can be clinically used. The CFI-Informant Version can be used when collateral information is needed or when the patient cannot participate in care, as with young children or individuals with cognitive impairments due to dementia, substance intoxication, or florid psychosis. In addition, there are two types of supplementary modules: (1) those that expand on sections of the core CFI and (2) those that address the cultural needs of particular populations. The CFI supplementary modules that expand on sections of the core CFI are those on the explanatory model; level of functioning; social network; psychosocial stressors; spirituality, religion, and moral traditions; cultural identity; coping and help-seeking; and the patient–clinician relationship. CFI supplementary modules for specific populations address school-age children and adolescents; older adults; immigrants and refugees; and caregivers. Psychotherapists have recognised the need to adapt evidence-based tools and interventions to the unique cultural needs and preferences of patients [24]. The semi-structured nature of these interviews and the diversity of topics furnish clinicians with interviews that can be customised according to clinical exigencies.

Given the growing interest in the CFI, the APA has posted the CFI for free on its website. All of the interviews can be found at the following weblink which can be copied and pasted into any Internet browser: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwi2_tnmxf3OAhWGKx4KHfIkB0YQFggcMAA&url=https%3A%2F%2Fwww.psychiatry.org%2FFile%2520Library%2FPsychiatrists%2FPractice%2FDSM%2FAPA_DSM5_Cultural-Formulation-Interview.pdf&usg=AFQjCNELEKr7I88QBl0En0mVxKIE5OLGbg&sig2=R-WOpqHH400rELTxCyWmJw&bvm=bv.131783435,d.dmo.

Video illustrations of the CFI are available free of charge through the APA via the website: https://www.appi.org/Lewis-Fernandez. The illustrations show clinicians using the core CFI in various clinical settings and the supplementary modules on level of functioning; spirituality, religion, and moral traditions; and older adults. An online training module on the core CFI is also available via www.nyculturalcompetence.org or by emailing cpihelp@nyspi.columbia.edu.

The rest of the chapter discusses how the core CFI responds to the recommendations of intercultural psychotherapists. We anchor this chapter to the core CFI since all of the interviews are based on its structure. The core CFI is comprised of four domains. The first is known as the Cultural Definition of the Problem and has three questions. Question #1 is “What brings you here today?” If patients provide little detail or only mention biomedical information, the follow-up probe question is: “People often understand their problems in their own way, which may be similar to or different from how doctors describe the problem. How would you describe your problem?” Question #2 is “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?” This question operationalises the recommendation in Table 4.1 that clinicians should endeavour to understand how cultural systems of knowledge and concepts are learned and transmitted in social groups. Tables 4.1 and 4.2 note that clinicians should communicate with language that is familiar to patients, and this question asks patients directly about how patients frame their problem linguistically. Question #3 is “What troubles you most about your problem?” Table 4.1 encourages clinicians to judge sociocultural deviance relative to the norms of a given community, and this question helps clinicians appreciate the problem’s impact on quality of life and level of functioning. Table 4.2 notes that therapists should pay attention to the behaviour patterns, beliefs, customs, and daily practices of patients, and the questions in this first domain start to uncover the patient’s perspective without presuming any prior fluency in biomedical concepts or vocabularies.

Questions #4–10 belong to the second domain known as Cultural Perceptions of Cause, Context, and Support. Questions #4–7 elicit the patient’s illness explanatory model on causes, social stressors, and social supports, a topic of abiding interest to cultural psychiatrists for privileging the patient’s understanding of health and illness [25]. Table 4.1 also notes that psychotherapists benefit from understanding patient theories of psychopathology. To that end, the rest of the CFI encourages clinicians to use the patient’s linguistic description of the illness wherever the placeholder “[PROBLEM]” appears. Question #4 is “Why do you think this is happening to you? What do you think are the causes of your [PROBLEM]?” To encourage a fuller expression of patient narratives, a follow-up to this question for clinicians is: “Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or many other causes.” Question #5 expands this question to include close associates as a way of recognising that culture is transacted within social groups: “What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?” Table 4.1 notes that clinicians should inquire about each patient’s culturally unique forms of social stressors and supports; questions #6 and #7 pursue these tasks. Question #6 is “Are there any kinds of support that make your [PROBLEM] better, such as support from family, friends, or others?” Question #7 is “Are there any kinds of stresses that make your [PROBLEM] worse, such as difficulties with money, or family problems?”

After the patient’s illness explanatory model has been elicited, the discussion turns to cultural identity. An introduction to this section affirms the well-established tenet that all psychotherapy is inherently an intercultural exercise because every individual has a unique background. The introduction is: “Sometimes, aspects of people’s background or identity can make their [PROBLEM] better or worse. By background or identity, I mean, for example, the communities you belong to, the languages you speak, where you or your family are from, your race or ethnic background, your gender or sexual orientation, or your faith or religion.” Question #8 asks the patient about background or identity: “For you, what are the most important aspects of your background or identity?” The goal of this question is to create a space for patients to self-select a cultural identity rather than for clinicians to assume an identity based on a group affiliation such as race or ethnicity without inquiring about its personal importance [26]. Question #9 asks the patient to reflect on how this identity relates to the current problem: “Are there any aspects of your background or identity that make a difference to your [PROBLEM]?” This question helps clinicians with integrating cultural information through diagnostic and treatment planning. Finally, Question #10 asks patients to consider cultural factors that may not immediately seem pertinent, but that could nevertheless impact care, such as problems with migration, gender roles, or intergenerational conflict: “Are there any aspects of your background or identity that are causing other concerns or difficulties for you?”

The next three questions belong to the third domain, which is known as Cultural Factors Affecting Self-Coping and Past Help Seeking. The third and fourth domains address culturally based goals of treatment, as recommended in Table 4.1. Question #11 is “Sometimes people have various ways of dealing with problems like [PROBLEM]. What have you done on your own to cope with your [PROBLEM]?” Question #12 normalises the possibility that patients may have sought help outside of the biomedical system: “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]?” To help patients identify successful modalities for the current illness episode, a probe question for #11 asks: “What types of help or treatment were most useful? Not useful?” Answers to this question may assist clinicians with creating treatment plans that incorporate previous forms of care that were helpful while avoiding those that were not. Question #13 asks about past barriers to treatment so that clinicians understand which resources could be mobilised in the present, ideally with the goal of tailoring treatment plans in a patient-centred way: “Has anything prevented you from getting the help you need?” A follow-up question lists examples of barriers: “For example, money, work or family commitments, stigma or discrimination, or lack of services that understand your language or background?”

The last three questions belong to the fourth domain, Cultural Factors Affecting Current Help Seeking. Question #14 asks the patient about current treatment preferences: “Now let’s talk some more about the help you need. What kinds of help do you think would be most useful to you at this time for your [PROBLEM]?” Question #15 explores treatment preferences that may be expressed by close associates: “Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?” As with Questions #2 and #5, this question explores the transmission of culturally related health information in social groups. Tables 4.1 and 4.2 caution clinicians to recognise cultural forms of transference and countertransference and to learn interviewing approaches to assess and discuss similarities and differences between patients’ and clinicians’ cultural backgrounds. Hence, Question #16 starts with an introduction: “Sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about this and is there anything that we can do to provide you with the care you need?” The introduction serves to normalise patient concerns around intercultural differences. Whether it is answered in the moment or deferred, the question signals to patients that the therapeutic encounter is a safe space to air differences. The question itself provides a template to clinicians for evoking reflection on intercultural differences and similarities.

Tables 4.1 and 4.2 note that psychotherapists should also attend to issues of countertransference. The core CFI does not address countertransference, but a supplementary module on the patient–clinician relationship includes the following questions for clinicians to ask themselves after the interview.

  1. 1.

    How did you feel about your relationship with the patient? Did cultural similarities and differences influence your relationship? In what way?

  2. 2.

    What was the quality of communication with the patient? Did cultural similarities and differences influence your communication? In what way?

  3. 3.

    If you used an interpreter, how did the presence of an interpreter or his/her way of interpreting influence your relationship or your communication with the patient and the information you received?

  4. 4.

    How do the patient’s cultural background or identity, life situation, and/or social context influence your understanding of his/her problem and your diagnostic assessment?

  5. 5.

    How do the patient’s cultural background or identity, life situation, and/or social context influence your treatment plan or recommendations?

  6. 6.

    Did the clinical encounter confirm or call into question any of your prior ideas about the cultural background or identity of the patient? If so, in what way?

  7. 7.

    Are there aspects of your own identity that may influence your attitudes toward this patient?

These questions operationalise Qureshi’s [14] attempt to foreground the dialogical nature of the therapeutic relationship. Question #1 of this supplementary module addresses the emotional connection between patients and clinicians, Questions #2 and #3 emphasise communication, and Questions #4–7 consider how the patient–clinician relationship affected the content of the session. These questions may help clinicians reflect on the cultural dynamics of transference and countertransference, whether they work in solo practice, multidisciplinary teams, or in academic settings where supervision of cases is possible.

We close this chapter with a discussion on the definitions of culture in DSM-5. DSM-5 offers a definition for culture in several locations. The introduction states: “Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, revised, and recreated within the family and other social systems and institutions. Diagnostic assessment must therefore consider whether an individual’s experiences, symptoms, and behaviors differ from sociocultural norms and lead to difficulties in adaptation in the cultures of origin and in specific social or familial contexts” ([23], p. 14). The DSM-5’s introduction to the CFI states that culture refers to:

  • The values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, veterans groups).

  • Aspects of an individual’s background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity.

  • The influence of family, friends, and other community members (the individual’s social network) on the individual’s illness experience ([23], p. 751).

The DSM-5 Cross-Cultural Issues Subgroup based these definitions upon a review of the medical and psychological literature on cultural assessments from 1994 to 2011 that was conducted to inform revisions for DSM-5. Our goal has not been to dictate a definition, but to provide a common conceptual framework for clinicians from discrepant backgrounds and orientations. The DSM-5 definition is consistent with the description of culture in Hsu and Tseng [3] and other seminal intercultural psychotherapy writings that represent culture as an individualised and context-dependent process of meaning-making rather than a static characteristic of social groups. A person-centred, process-based definition such as the one that informs the CFI is more conducive to self-understanding and the negotiation of behaviour change in psychotherapy than a more static, group-based approach that is less sensitive to context and to individual variation. We hope that intercultural psychotherapists will engage with these concepts as the CFI disseminates, presenting clinicians with more opportunities to devise and revise cultural tools for improving clinical care.

Conclusion

Intercultural psychotherapists have described a series of challenges and recommendations for clinicians who emphasise the cross-cultural aspects of psychotherapy. The DSM-5 Cultural Formulation Interview is a systematic tool for case formulation that can help clinicians operationalise these recommendations into specific questions during clinical assessment and treatment implementation. The person-centred cultural information thus obtained may be used to guide treatment choice, negotiate psychotherapy goals, understand transference and countertransference reactions, and develop the therapeutic alliance. The CFI can serve as a useful standardised framework to fulfil the tasks of intercultural psychotherapy.