Skip to main content

Advertisement

Log in

Barriers to Implementing the DSM-5 Cultural Formulation Interview: A Qualitative Study

  • Original Paper
  • Published:
Culture, Medicine, and Psychiatry Aims and scope Submit manuscript

Abstract

The Outline for Cultural Formulation (OCF) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) marked an attempt to apply anthropological concepts within psychiatry. The OCF has been criticized for not providing guidelines to clinicians. The DSM-5 Cultural Issues Subgroup has since converted the OCF into the Cultural Formulation Interview (CFI) for use by any clinician with any patient in any clinical setting. This paper presents perceived barriers to CFI implementation in clinical practice reported by patients (n = 32) and clinicians (n = 7) at the New York site within the DSM-5 international field trial. We used an implementation fidelity paradigm to code debriefing interviews after each CFI session through deductive content analysis. The most frequent patient threats were lack of differentiation from other treatments, lack of buy-in, ambiguity of design, over-standardization of the CFI, and severity of illness. The most frequent clinician threats were lack of conceptual relevance between intervention and problem, drift from the format, repetition, severity of patient illness, and lack of clinician buy-in. The Subgroup has revised the CFI based on these barriers for final publication in DSM-5. Our findings expand knowledge on the cultural formulation by reporting the CFI’s reception among patients and clinicians.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  • Adeponle, Ademola B., Brett D. Thombs, Danielle Groleau, Eric Jarvis, and Laurence J. Kirmayer 2012 Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Diverse Patients. Psychiatric Services 63(2): 147-153.

    Article  Google Scholar 

  • Aggarwal, Neil Krishan 2010 Reassessing Cultural Evaluations in Geriatrics: Insights from Cultural Psychiatry. Journal of the American Geriatrics Society 58(11): 2191-2196.

    Article  Google Scholar 

  • Aggarwal, Neil Krishan 2012a The Psychiatric Cultural Formulation: Translating Medical Anthropology into Clinical Practice. Journal of Psychiatric Practice 18(2): 73-85.

    Article  Google Scholar 

  • Aggarwal, Neil Krishan 2012b Hybridity and Intersubjectivity in the Clinical Encounter: Impact on the Cultural Formulation. Transcultural Psychiatry 49(1): 121–139.

  • Aggarwal, Neil Krishan 2013 Cultural Psychiatry, Medical Anthropology, and the DSM-5 Field Trials. Medical Anthropology: Cross-Cultural Studies in Illness and Health. doi:10.1080/01459740.2013.776047.

  • Aggarwal, Neil Krishan, and Robert Rohrbaugh 2011 Teaching Cultural Competency through an Experiential Seminar on Anthropology and Psychiatry. Academic Psychiatry 35(5): 331-334.

    Article  Google Scholar 

  • Alarcón, Renato D. 2009 Culture, Cultural Factors and Psychiatric Diagnosis: Review and Projections. World Psychiatry 8(3): 131-139.

    Google Scholar 

  • American Psychiatric Association 2000 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Arlington: American Psychiatric Publishing, Inc.

    Google Scholar 

  • American Psychiatric Association 2012 DSM-5 Cultural Formulation Interview. http://www.dsm5.org/proposedrevision/Documents/DSM5%20Draft%20CFI.pdf. Accessed June 25, 2012.

  • Atkinson, Sarah J. 1993 Anthropology in research on the quality of health services. Cadernos de Saúde Pública 9(3): 283-299.

    Article  Google Scholar 

  • Bäärnhielm, Sofie 2008 Introducing the Cultural Formulation to Mental Health Care in Stockholm, Sweden. In Cultural Formulation: A Reader for Psychiatric Diagnosis. Lanham: Jason Aronson.

  • Bäärnhielm, Sofie, and Marco Scarpinati Rosso 2009 The Cultural Formulation: A Model to Combine Nosology and Patients’ Life Context in Psychiatric Diagnostic Practice. Transcultural Psychiatry 46(3): 406-428.

    Article  Google Scholar 

  • Bernard, H. Russel 2006 Research Methods in Anthropology: Qualitative and Quantitative Approaches. Oxford: AltaMira Press.

    Google Scholar 

  • Bibeau, Gilles 1997 Cultural Psychiatry in a Creolizing World: Questions for a New Research Agenda. Transcultural Psychiatry 34(1): 9-41.

    Article  Google Scholar 

  • Canino, Ian, Glorisa Canino, and William Arroyo 1998 Cultural Considerations for Childhood Disorders: How Much was Included in DSM-IV? Transcultural Psychiatry 35(3): 343-355.

    Article  Google Scholar 

  • Carpenter-Song, Elizabeth A., Megan Nordquest Schwallie, and Jeffrey Longhofer 2007 Cultural Competence Reexamined: Critique and Directions for the Future. Psychiatric Services 58(10): 1362–1365.

    Article  Google Scholar 

  • Clarke, Diana E., William E. Narrow, Darryl A. Regier, S. Janet Kuramoto, David J. Kupfer, Emily A. Kuhl, Lisa Greiner, and Helena C. Kraemer 2013 DSM-5 Field Trials in the United States and Canada, Part I: Study Design, Sampling Strategy, Implementation, and Analytic Approaches. American Journal of Psychiatry 170 (1): 43-58.

    Article  Google Scholar 

  • Davis, Dona L. 1998 The Sexual and Gender Identity Disorders. Transcultural Psychiatry 35(3): 401-412.

    Article  Google Scholar 

  • Elo, Satu, and Helvi Kyngäs 2008 The Qualitative Content Analysis Process. Journal of Advanced Nursing 62(1): 107-115.

    Article  Google Scholar 

  • Epstein, Joan, Peggy Barker, Michael Vorburger, and Christine Murtha 2002 Serious Mental Illness and its Co-occurrence with Substance Use Disorders, 2002. Rockville: Substance Abuse and Mental Health Services Administration.

    Google Scholar 

  • Fung, Kenneth, Lisa Andermann, Ari Zaretsky, and Hung-Tat Lo 2008 An Integrative Approach to Cultural Competence in the Psychiatric Curriculum. Academic Psychiatry 32(4): 272-282.

    Article  Google Scholar 

  • Fraser, Mark W., and Maeda J. Galinsky 2010 Steps in Intervention Research: Designing and Developing Intervention Programs. Research on Social Work Practice 20(5): 459-466.

    Article  Google Scholar 

  • Gearing, Robin Edward, Nabila El-Bassel, Angela Ghesquiere, Susanna Baldwin, John Gillies, and Evelyn Ngeow 2011 Major Ingredients of Fidelity: A Review and Scientific Guide to Improving Quality of Intervention Research Implementation. Clinical Psychology Review 31(1): 79-88.

    Article  Google Scholar 

  • Good, Byron 1994 Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press.

    Google Scholar 

  • Good, Byron 1996 Culture and DSM-IV: Diagnosis, Knowledge, and Power. Culture, Medicine and Psychiatry 20(2): 127-132.

    Article  Google Scholar 

  • Good, Byron, and Mary-Jo DelVecchio Good 1980 The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice. In The Relevance of Social Science for Medicine. Dordrecht: D. Reidel Publishing Company.

  • Graneheim, U. H., and B. Lundman 2004 Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Education Today 24(2): 105-112.

    Article  Google Scholar 

  • Gregg, Jessica, and Somnath Saha 2006 Losing Culture on the Way to Competence: The Use and Misuse of Culture in Medical Education. Academic Medicine 81(6): 542–547.

    Article  Google Scholar 

  • Groen, Simon 2009 The Brief Cultural Interview 2009 (BCI-09). http://www.mcgill.ca/iccc/sites/mcgill.ca.iccc/files/Interview.pdf. Accessed June 13, 2012.

  • Group for the Advancement of Psychiatry 2001 Cultural Assessment in Clinical Psychiatry. Washington, DC: American Psychiatric Publishing, Inc.

    Google Scholar 

  • Harris, Treniece Lewis, Joy McQuery, Barbara Raab and Shekinah Elmore 2008 Multicultural Psychiatric Education: Using the DSM-IV-TR Outline for Cultural Formulation to Improve Resident Cultural Competence. Academic Psychiatry 32(4): 306-312.

    Article  Google Scholar 

  • Hsieh, Hsiu-Fang, and Sarah E. Shannon 2005 Three Approaches to Qualitative Content Analysis. Qualitative Health Research 15(9): 1277-1288.

    Article  Google Scholar 

  • Jayasuriya, Laksiri 2008 Constructions of Culture and Identity in Contemporary Social Theorising. International Journal of Culture and Mental Health 1(1): 30-43.

    Article  Google Scholar 

  • Jenks, Angela C. 2011 From “List of Traits” to “Open-Mindedness”: Emerging Issues in Cultural Competence Education. Culture, Medicine and Psychiatry 35(2): 209-235.

    Article  Google Scholar 

  • Jenkins, Janis H. 1998 Diagnostic Criteria for Schizophrenia and Related Psychotic Disorders: Integration and Suppression of Cultural Evidence in DSM-IV. Transcultural Psychiatry 35(3): 357-376.

    Article  Google Scholar 

  • Jenkins, Janis H. 2007 Anthropology and Psychiatry: The Contemporary Convergence. In Textbook of Cultural Psychiatry. New York: Cambridge University Press.

  • Katz, Arlene M., and Margarita Alegría 2009 The Clinical Encounter as Local Moral World: Shifts of Assumptions and Transformation in Relational Context. Social Science and Medicine 68(7): 1238-1246.

    Article  Google Scholar 

  • Kirmayer, Laurence J. 1998 The Fate of Culture in DSM-IV. Transcultural Psychiatry 35(3): 339-342.

    Article  Google Scholar 

  • Kirmayer, Laurence J., Danielle Groleau, Jaswant Guzder, Caminee Blake, and Eric Jarvis 2003 Cultural consultation: a model of mental health service for multicultural societies. Canadian Journal of Psychiatry 48(3): 145-153.

    Google Scholar 

  • Kirmayer, Laurence J., Cécile Rousseau, Jaswant Guzder, and G. Eric Jarvis 2008a Training Clinicians in Cultural Psychiatry: A Canadian Perspective. Academic Psychiatry 32(4): 313-319.

  • Kirmayer, Laurence J., Brett D. Thombs, Tomas Jurick, G. Eric Jarvis, and Jaswant Guzder 2008b Use of an Expanded Version of the DSM-IV Outline for Cultural Formulation on a Cultural Consultation Service. Psychiatric Services 59(6): 683–686.

  • Kleinman, Arthur 1977 Lessons From a Clinical Approach to Medical Anthropological Research. Medical Anthropology Quarterly 8(4): 11-15.

    Google Scholar 

  • Kleinman, Arthur 1978 Clinical Relevance of Anthropological and Cross-Cultural Research: Concepts and Strategies. American Journal of Psychiatry 135(4): 427-431.

    Google Scholar 

  • Kleinman, Arthur 1985 Interpreting Illness Experience and Clinical Meanings: How I See Clinically Applied Anthropology. Medical Anthropology Quarterly 16(3): 69-71.

    Article  Google Scholar 

  • Kleinman, Arthur 1988a The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.

    Google Scholar 

  • Kleinman, Arthur 1988b Rethinking Psychiatry. New York: The Free Press.

    Google Scholar 

  • Kleinman, Arthur 1996 How is Culture Important for DSM-IV? In Culture and Psychiatric Diagnosis: A DSM-IV Perspective. Washington, DC: American Psychiatric Press, Inc.

  • Kleinman, Arthur 2008 Why Psychiatry and Cultural Anthropology Still Need Each Other. Psychiatry 64(1): 14-16.

    Google Scholar 

  • Kleinman, Arthur, and Peter Benson 2006 Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Medicine 3(10): e294.

    Article  Google Scholar 

  • Kleinman, Arthur, Leon Eisenberg, and Byron Good 1978 Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. Annals of Internal Medicine 88(2): 251-258.

    Article  Google Scholar 

  • Krippendorff, Klaus 2013 Content Analysis: An Introduction to its Methodology. Thousand Oaks: Sage Publications.

    Google Scholar 

  • Lewis-Fernández, Roberto 1996 Cultural Formulation of Psychiatric Diagnosis. Culture, Medicine, and Psychiatry 20(3): 133-144.

    Article  Google Scholar 

  • Lewis-Fernández, Roberto 1998 A Cultural Critique of the DSM-IV Dissociative Disorders Section. Transcultural Psychiatry 35(3): 387-400.

    Article  Google Scholar 

  • Lewis-Fernández, Roberto 2009 Editorial: The Cultural Formulation. Transcultural Psychiatry 46(3): 379-382.

    Article  Google Scholar 

  • Lewis-Fernández, Roberto, and Naelys Díaz 2002 The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter. Psychiatric Quarterly 73(4): 271-95.

    Article  Google Scholar 

  • Lim, Russell F. 2006 Clinical Manual of Cultural Psychiatry. Washington, D.C.: American Psychiatric Publishing, Inc.

    Google Scholar 

  • Lim, Russell F., John S. Luo, Shannon Suo, and Robert E. Hales 2008 Diversity Initiatives in Academic Psychiatry: Applying Cultural Competence. Academic Psychiatry 32(4): 283-290.

    Article  Google Scholar 

  • Lim, Russell F., Ronald J. Diamond, Jacquelyn B. Chang, Annelle B. Primm, and Francis G. Lu 2008 Using Non-Feature Films to Teach Diversity, Cultural Competence, and the DSM-IV-TR Outline for Cultural Formulation. Academic Psychiatry 32(4): 291-298.

    Article  Google Scholar 

  • Lu, Francis G. 2006 DSM-IV Outline for Cultural Formulation: Bringing culture into the clinical encounter. Focus 4(1): 9-10.

    Google Scholar 

  • Manson, Spero M., and Arthur Kleinman 1998 DSM-IV, Culture and Mood Disorders: A Critical Reflection on Recent Progress. Transcultural Psychiatry 35(3): 377-386.

    Article  Google Scholar 

  • Martínez, Luis Caballero 2008 Formulación Cultural de Casos Psiquiátricos DSM-IV-tr. In Seminario Sobre: Formulación y Abordaje Cultural de Casos Psiquiátricos. Madrid: Luzán 5, S. A.

  • Martínez, Luis Caballero 2009 DSM-IV-TR Cultural Formulation of Psychiatric Cases: Two Proposals for Clinicians. Transcultural Psychiatry 46(3): 506-523.

  • McGarvey, Stephen T. 2009 Interdisciplinary Translational Research in Anthropology, Nutrition, and Public Health. Annual Review of Anthropology 38: 233-249.

    Article  Google Scholar 

  • Mezzich, Juan E. 2008 Cultural Formulation: Development and Critical Review. In Cultural Formulation: A Reader for Psychiatric Diagnosis. Lanham: Jason Aronson.

  • Mezzich, Juan E., Giovanni Caracci, Horacio Fabrega, Jr., and Laurence J. Kirmayer. 2009 Cultural Formulation Guidelines. Transcultural Psychiatry 46(3): 383–405.

  • Mezzich, Juan E., Laurence J. Kirmayer, Arthur Kleinman, Horacio Fabrega, Dolores L. Parron, Byron J. Good, Keh-Ming Lin, and Spero Manson 1999 The Place of Culture in DSM-IV. Journal of Nervous and Mental Disease 187(8): 457-464.

    Article  Google Scholar 

  • Narrow, William E., Diana E. Clarke, S. Janet Kuramoto, Helena C. Kraemer, David J. Kupfer, Lisa Greiner, and Darrel A. Regier 2013 DSM-5 Field Trials in the United States and Canada, Part III: Development and Reliability Testing of a Cross-Cutting Symptom Assessment for DSM-5. American Journal of Psychiatry 170(1): 71-82.

    Article  Google Scholar 

  • National Institute of Health 2005 RFA-RM-06-002: Institutional Clinical and Translational Science Award. http://grants.nih.gov/grants/guide/rfa-files/RFA-RM-06-002.html. Accessed November 14, 2012.

  • Nichter, Mark 1981 Idioms of Distress: Alternatives in the Expression of Psychosocial Distress: A Case Study from South India. Culture, Medicine and Psychiatry 5(4): 379-408.

    Article  Google Scholar 

  • Palinkas, Lawrence A., Gregory A. Aarons, Sarah Horwitz, Patricia Chamberlain, Michael Hurlburt, and John Landsverk 2011 Mixed Method Designs in Implementation Research. Administration and Policy in Mental Health and Mental Health Services Research 38(1): 44-53.

    Article  Google Scholar 

  • Peteet, John R., Francis G. Lu, and William E. Narrow 2010 Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-V. Arlington: American Psychiatric Publishing, Inc.

    Google Scholar 

  • Pfeiffer, James, and Rachel Chapman 2010 Anthropological Perspectives on Structural Adjustment and Public Health. Annual Review of Anthropology 39: 149-165.

    Article  Google Scholar 

  • Pope, Catherine, and Nick Mays 1995 Reaching the Parts Other Methods Cannot Reach: An Introduction to Qualitative Methods in Health and Health Services Research. BMJ 311(1): 42-45.

    Article  Google Scholar 

  • Proctor, Enola. John Landsverk, Gregory Aarons, David Chambers, Charles Glisson, and Brian Mittman 2009 Implementation Research in Mental Health Services: An Emerging Science with Conceptual, Methodological, and Training Challenges. Administration and Policy in Mental Health and Mental Health Services Research. 36(1): 24-34

    Article  Google Scholar 

  • QSR International 2012 NVivo.

  • Rogler, Lloyd H, and Dharma E. Cortes 1993 Help-Seeking Pathways: A Unifying Concept in Mental Health Care. American Journal of Psychiatry 150(4): 54-561.

    Google Scholar 

  • Rohlof, Hans 2008 The Cultural Interview in the Netherlands: The Cultural Formulation in Your Pocket. In Cultural Formulation: A Reader for Psychiatric Diagnosis. Lanham: Jason Aronson.

  • Rohlof, Hans, Jeroen W. Knipscheer, and Rolf J. Kleber 2009 Use of the Cultural Formulation with Refugees. Transcultural Psychiatry 46(3): 487-505.

    Article  Google Scholar 

  • Rounsaville, Bruce J., Kathleen M. Carroll, and Lisa S. Onken 2001 A Stage Model of Behavioral Therapies Research: Getting Started and Moving on From Stage I. Clinical Psychology: Science and Practice 8: 133-142.

    Article  Google Scholar 

  • Saha, Somnath, Mary Catherine Beach, Lisa A. Cooper 2008 Patient Centeredness, Cultural Competence and Healthcare Quality. Journal of the National Medical Association 100(11): 1275-1285.

    Google Scholar 

  • Santiago-Irizarry, Vilma 1996 Culture as Cure. Cultural Anthropology 11(1): 3-24.

    Article  Google Scholar 

  • Shaw, Susan J., and Julie Armin 2011 The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care. Culture, Medicine and Psychiatry 35(2): 236-261.

    Article  Google Scholar 

Download references

Acknowledgments

Dr. Aggarwal was supported by a NIMH T32 post-doctoral fellowship in clinical research. Dr. Aggarwal was an advisor to the DSM-5 Cultural Issues Subgroup of which Dr. Lewis-Fernández was the chairperson. The authors acknowledge a Grant from the American Psychiatric Association for the DSM-5 field trial.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Neil Krishan Aggarwal.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Aggarwal, N.K., Nicasio, A.V., DeSilva, R. et al. Barriers to Implementing the DSM-5 Cultural Formulation Interview: A Qualitative Study. Cult Med Psychiatry 37, 505–533 (2013). https://doi.org/10.1007/s11013-013-9325-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11013-013-9325-z

Keywords

Navigation