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Clinician Reasoning in the Use of Cultural Formulation to Resolve Uncertainty in the Diagnosis of Psychosis

Abstract

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians’ reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake ‘psychosis’ symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians’ reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

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Fig. 1

Notes

  1. 1.

    Metzl (2009) provides a gripping account of how in the wake of psychiatric deinstitutionalization and black civil rights agitations in the 1960s US, the diagnostic label ‘schizophrenia’ previously used as preferred diagnostic label for white middle-class women morphed radically into a diagnostic label applied preferentially to young, poor, black males. Metzl traces the origins of the stereotype of young, black male patients as dangerous, angry, criminal and as coming to clinical attention through police and other coercive methods, to this period in the history of America and American psychiatry.

  2. 2.

    Koro is a syndrome in which an individual has the belief his penis is retracting into the abdomen, and that death will ensue if this is not halted (Buckle et al. 2007). It occurs in sporadic and epidemic forms in a variety of cultures from Southeast Asia, the Indian subcontinent and Africa.

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Correspondence to Ademola B. Adeponle.

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The study was completed as part of the fulfillment of the requirements for the M.Sc. by the first author.

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Adeponle, A.B., Groleau, D. & Kirmayer, L.J. Clinician Reasoning in the Use of Cultural Formulation to Resolve Uncertainty in the Diagnosis of Psychosis. Cult Med Psychiatry 39, 16–42 (2015). https://doi.org/10.1007/s11013-014-9408-5

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Keywords

  • Cultural formulation
  • Psychosis diagnosis
  • Clinician reasoning and bias
  • Immigrants and refugees
  • Cultural competence