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

Abstract

The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients—11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.

The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice

“…Three studies reported on the perspectives of family members who accompanied patients (Hinton et al., 2015; Paralikar et al., 2015, 2020). The first of these (Hinton et al., 2015) explored perceptions of the CFI’s feasibility, acceptability, and clinical utility from patient companions in India, Kenya, and the Netherlands during the pilot field trial, and found that they rated the CFI positively on all three domains.…”

“…A study from an Indian field trial site found that patients with common mental disorders rated the CFI’s acceptability and clinical utility higher than did patients with psychosis and clinicians; in fact, patients with psychosis rated acceptability and clinical utility lower than patients without psychosis and clinicians (Paralikar et al., 2015). Another Indian study by the same research team used qualitative analyses of patient and clinician debriefing interviews from the field trial to propose revisions to the OCF that situated narratives within social, political, and economic contexts (Paralikar et al., 2020). A study from the Dutch field trial site found slightly lower ratings of feasibility, acceptability, and clinical utility relative to the mean values of the overall field trial, though still in the positive range (Rohlof et al., 2017).…”

The Cultural Formulation Interview: Progress to date and future directions

“…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.…”

“…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.…”

“…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).…”