Introduction

The release of a revision to the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) in 2022 is an opportunity to contemplate a decades-long collaboration among medical anthropologists in mental health settings and cultural psychiatrists trained in anthropology who have introduced ethnographic approaches to caregiving (Good 1996; Kleinman 1988). I belong to the latter, completing a post-doctoral fellowship in clinical anthropology after psychiatry training. For over a decade, I have been a consultant to the DSM-5 Cross-Cultural Issues Subgroup (DCCIS). My research, funded by the National Institute of Mental Health (NIMH), has focused on the possibilities and limitations of translating anthropological theories into practices for clinicians.

This collaboration has led to a 16-item, semi-structured interview published in 2013 for DSM-5 known as the Cultural Formulation Interview (CFI)Footnote 1 so clinicians can assess cultural factors related to diagnosis and treatment with patients (American Psychiatric Association 2013). Anthropologists have contributed to the ideas underpinning the CFI for over thirty years, starting with DSM-IV (Kleinman 1996). In 1991, the APA consulted with over fifty psychiatrists, psychologists, and anthropologists from a NIMH Group on Culture and Diagnosis (hereafter: “NIMH Group”) to revise DSM-III-R into DSM-IV (Kirmayer 1998; Mezzich 2008). The NIMH Group synthesized scientific evidence for the APA Task Force on DSM-IV to show that cultural factors influence diagnosis by shaping the content and meaning of symptoms for patients and clinicians, providing the scientific rationale to group symptoms into categories of disorders, and influencing norms of communication (Mezzich et al. 1999). The NIMH Group suggested that DSM-IV include an Outline for Cultural Formulation (OCF) based on social theories for clinicians to organize information across five domains: (1) cultural identity of the individual, (2) cultural explanations of illness, (3) cultural factors related to the psychosocial environment and levels of functioning, (4) cultural aspects of the patient–clinician relationship, and (5) cultural factors related to diagnosis and treatment (Mezzich 2008; Mezzich et al. 1999). After DSM-IV’s publication, Culture, Medicine, and Psychiatry and Transcultural Psychiatry published cases from clinicians on the OCF’s use in patient care (Lewis-Fernández 1996, 2009).

In revising psychiatric diagnoses from DSM-IV to DSM-5, the APA assembled cultural psychiatrists, cultural psychologists, and psychiatric anthropologists into the DCCIS to examine the OCF’s implementation and need for revisions. The DCCIS reviewed studies on cultural assessments in mental health from 1965 to 1994 and case studies on the OCF since 1994 across seven languages (Lewis-Fernández et al. 2014). As an indication of its usefulness, clinicians using OCF-based interviews on cultural consultation services re-diagnosed patients—mostly from psychotic to non-psychotic disorders—by eliciting information about explanatory models of illness and social relationships that anthropological theories added to the standard assessment (Adeponle et al. 2012; Bäärnhielm, Wistedt, and Rosso 2015). Nonetheless, most clinicians did not understand the OCF’s social science underpinnings or how to use it in patient care (Lewis-Fernández et al. 2014). Furthermore, the different types of OCF-based interviews used on cultural consultation services around the world prevented broad conclusions being drawn about improved clinical outcomes resulting from a standardized intervention (Alarcón 2009). In response to these criticisms, the DCCIS created a 14-question CFI from the OCF, field tested it with 321 patients and 75 clinicians in six countries in 2011 and 2012, and revised the CFI into its current 16 questions based on patient and clinician feedback (Aggarwal et al. 2016). Field trial patients and clinicians found the CFI feasible, acceptable, and useful, with clinicians completing it in 22–26 min (Lewis-Fernández et al. 2017). Anthropologists uninvolved in DSM-5 have called the CFI “inspiring” in applying anthropological theories (Kleinman 2016) and “perhaps the most concrete expression of the contemporary convergence of anthropology and psychiatry” (Jenkins 2018:24).

The CFI has attracted significant attention from clinicians. The APA’s Practice Guidelines for the Psychiatric Evaluation of Adults states, “For clinicians who lack experience in assessing cultural factors, the DSM-5 Cultural Formulation Interview offers a semi-structured framework for initiating questioning” (American Psychiatric Association 2016:29–30). To promote CFI dissemination, the APA (2020a) has produced an online training video for clinicians that is free of cost. The American Association of Child and Adolescent Psychiatry (2016) has endorsed CFI use to fulfill a “systems-based practice” competency for all trainees, stating, “DSM5 also includes a Cultural Formulation Interview (CFI) with suggested questions to assess socio-cultural aspects of psychiatric presentation” (p. 8). Moreover, investigators have generated programmatic research: a systematic review of peer-reviewed publications on the CFI from 2013 to 2020 identified 25 studies from around the world (Aggarwal et al. 2020).

Even so, anthropologists have critiqued the culture concept in the CFI. Anne Leseth (2015) has questioned the cultural formulation approach, noting, “In striking contrast to its current use in anthropology, the concept of culture tends to be defined in medicine as something possessed by the patient and not the doctor” (p. 188). Stefan Ecks (2016) has termed the culture sections in DSM-5 as “shallow,” contending that, “What is presented as ‘culture’ in the DSM-V is too focused on meaning and not enough on practice. Its culture sections are based on the hermeneutic, meaning-centred tradition in anthropological theory” (p. 143). Anna Bredström (2019) has warned that the CFI could exaggerate cultural differences: “Whereas diagnostic criteria generally focus on symptoms and symptom severity in a decontextualized manner, the CFI is all about contextualising symptoms. Accordingly, one may conclude that cultural aspects translate into contextualising symptoms of mental distress, but the reverse is also true—that is, to contextualise symptoms becomes equal with cultural difference” (pp. 359–360). These critiques have been substantiated in some practice settings. In Mexico, researchers found that, “Question 8 of the CFI appears explicitly related to culture, asking patients how their ‘background or identity’ influences their presenting problem. Across our observations of CFI interviews, this question was most frequently misunderstood, or not understood at all, by patients; providers also struggled to explain the meaning of the question to patients” (Ramírez Stege and Yarris 2017:474). Nearly all 17 providers in Denmark who treated immigrant patients “recognized the paradox that the CFI—despite its ability to facilitate alliance and its intention of applying a dynamic approach to cultures—could also lead to experiences of distance and othering” (Lindberg et al. 2022). Such critiques raise perceptive questions about the CFI’s theoretical foundations which remain unanswered.

In discussing US settings with hyperdiverse patient populations, the social scientists Mary-Jo DelVecchio Good and Seth Hannah (2015) posed two questions that trace the culture concept in psychiatry while simultaneously examining psychiatry as a product of cultural forces: “Does the language of cultural competence in contemporary medicine rely on ideas of these earlier eras, of coherent ethnic communities sharing coherent cultures? How were changing demographics and the new immigration influencing ‘culture concepts’” (p. 200). This article extends these questions to the OCF and CFI by analyzing the culture concept’s evolution through official publications from the DSM-IV, DSM-5, and DSM-5-TR revisions alongside contemporaneous scholarship in anthropology and psychiatry. According to the APA’s marketing materials, the DSM is the authoritative diagnostic guide for the United States and much of the world (American Psychiatric Association 2022b). Tracking the culture concept’s evolution highlights the tension of “whether it is possible to use cultural categories to develop evidence-based practice guidelines in mental health services at this moment when these categories are challenged by the increasing diversity of patient populations and newer theories of culture” (Good and Hannah 2015:199). This evolution shows how a group of mostly US experts used a concept of culture that was tested with minoritized, ethnoracial individuals for DSM-IV before accommodating growing notions of diversity for DSM-5-TR. The article proposes a cultural formulation that treats culture not as an object solely possessed by the patient or unduly focused on meanings, but as an intersubjective process co-constructed in each patient–clinician dyad that also examines the clinician’s practices. An intersubjective model of culture prompts a reconsideration of other sections in the DSM that utilize a prior concept of culture, examples of which are analyzed in the final section. I acknowledge one limitation from the outset. My analysis rests exclusively on published articles and reports, not interviews with participants. Starting with the revision from DSM-IV-TR to DSM-5, the APA has enforced confidentiality agreements among contributors, which critics have challenged for restricting transparency (Collier 2010). Those of us who contributed to DSM-5 and DSM-5-TR have also signed these agreements and cannot reveal unofficial deliberations of the DCCIS. Even though published materials do not capture all viewpoints on a topic, peer-reviewed publications are one standard by which the APA Task Force determines whether to consider revisions to current criteria and constructs (Kendler et al. 2009). For this reason, making arguments about the culture concept’s evolution throughout the DSM revisions by analyzing published materials is one way to trace how certain ideas assume official, institutional recognition.

DSM-IV and the Minoritization of the Culture Concept

Seventeen years before Eck’s observation about the DSM-5’s culture sections, the NIMH Group acknowledged the limitations of a singular theoretical orientation after DSM-IV’s publication, writing: “Although a meaning-centered anthropological approach directly or indirectly informed our analyses, it should be recognized that cultural psychiatry involves an amalgam of principles and generalizations drawn from several social sciences and a broadly based clinical psychiatry. There was too little attention to social factors in the cultural considerations” (Mezzich et al. 1999). The NIMH Group recommended “further research on the cultural framework for diagnosis and care” for future DSM revisions (Mezzich et al. 1999). Therefore, the social fact to explain is the endurance of a specific culture concept from DSM-IV through DSM-5. This endeavor requires understanding how DSM-IV conceptualized culture, which is not straightforward since the APA Task Force on DSM-IV did not adopt the NIMH Group’s recommendation to include definitions of culture and ethnicity (Kirmayer 1998; Mezzich et al. 1999). Such clarity would have helped clinicians, as one NIMH Group member counted over 200 definitions for culture during the revision process (Alarcón 1995).

The NIMH Group recommended definitions for culture as “meanings, values, and behavioral norms that are learned and transmitted in the dominant society and within its social groups” and ethnicity as “social groupings which distinguish themselves from other groups based on ideas of shared descent and aspirations, as well as to behavioral norms and forms of personal identity associated with such groups” (Lu, Lim, and Mezzich 2008). The NIMH Group also recommended that DSM-IV’s Introduction emphasize intracultural diversity and the importance of patient–clinician cultural differences (Lewis-Fernández and Kleinman 1995). Instead of these recommendations, DSM-IV’s Introduction included this caution on culture and diagnosis:

Clinicians are called on to evaluate individuals from numerous different ethnic groups and cultural backgrounds (including many who are recent immigrants). Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IV classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture (American Psychiatric Association 1994:xxiv).

Aspects of the prevailing culture concept can be inferred from this passage when analyzed against the NIMH Group’s recommendations. DSM-IV inherited intellectual trends from the cultural anthropology of the 1970s and 1980s that dichotomized nature and culture rather than studying their interrelations and overemphasized monolithic beliefs and behaviors within unfamiliar communities that minimized internal differences (Khan 2017). Members of the NIMH Group appreciated the need to examine cultural, biological, and environmental interrelationships, observing that DSM-IV categories were organized according to hypothesized biological dysfunctions that were still unproven but nevertheless assumed to be universal with differing manifestations of symptoms across societies (Fabrega Jr. 1992). The APA Task Force on DSM-IV propagated this universality in having DSM-IV’s editors delete information on cultural differences related to epidemiology, symptoms, illness course, and treatment response for specific disorders (Kleinman 1997). In doing so, the APA positioned psychiatric disorders in DSM-IV as objective medical categories, not social constructions of behaviors that rest on a clinician’s inherently cultural judgments of normality and deviancy (Fabrega Jr. 1995).

And yet, there was an underlying assumption within the APA that individuals could act as representatives of minoritized populations. Within the NIMH Group, anthropologists were expected to appraise the validity of psychiatric diagnoses for non-American populations based on their international fieldwork experiences whereas the non-White psychiatrists all came from minoritized ethnoracial groups in the United States (Littlewood 1992). This tendency is reflected in an official APA book titled Culture and Psychiatric Diagnosis: A DSM-IV Perspective that included contributions from members of the NIMH Group. Apart from chapters on the relationship between cultural factors and categories of disorders such as psychosis, substance use, mood, and anxiety, there are single-authored chapters titled “African American Perspectives,” “Native American Perspectives,” “Asian American Perspectives,” and “Hispanic Perspectives.” These trends lead to two inferences about how the APA Task Force understood culture: (1) culture was treated closely to race and ethnicity, and (2) an individual was expected to articulate the views of a minoritized group. Throughout the 1990s, the APA’s concept of culture reflected US Census-based categories that conflated linguistic, geographic, ethnic and racial diversity for the political purpose of acknowledging multiculturalism (Kirmayer 2012).

Culture and Psychiatric Diagnosis also included views from anthropologists about how clinicians could assess for patient cultural factors to supplement DSM-IV’s multiaxial system, with mental health and substance use disorders listed on Axis I, personality disorder and mental retardation [the expression used at that time] on Axis II, general medical conditions on Axis III, psychosocial and environmental problems on Axis IV, and a Global Assessment of Functioning score on Axis V. Debates focused on operationalizing a suggestion from Byron Good and Mary-Jo DelVecchio Good for a “cultural axis” that would represent the patient’s emic perspective by recording “the culture-specific illness category, the explanatory model, the illness idiom, the predominant care-seeking pattern, and the perceived level of disability” (Good and Good 1986:21). Horacio Fabrega Jr. (1996) proposed examining “the extent to which cultural and linguistic factors (local traditions of meaning) cloud the presentation of symptoms” (p. 10). Peter Guarnaccia (1996) recommended recording popular illness categories, the patient’s understanding of the disorder, assessment of language use, acculturation/biculturalism, and religious beliefs and practices. Arthur Kleinman (1996) suggested recording how patients “self describe their ethnic or cultural identity as well as their perceived degree of acculturation, language fluency, religious affiliation, and any special dietary or other practices that could be used to assess the degree of practicing behavioral ethnicity” (p. 22). Kleinman (1996) also added that “patients’ or families’ explanatory models would be elicited to assess culturally influential beliefs on illness experience” (p. 22).

The NIMH Group ultimately abandoned a cultural axis for the OCF. As Juan Mezzich (2008), the Group’s Chairperson, wrote, “The initiative for conceiving a cultural formulation emerged when the possibility of a ‘cultural axis’ was considered” (p. 89). But the Group concluded that to preserve the patient’s emic perspective, diagnostic axes “were not considered appropriate for articulating a cultural statement” (Mezzich 2008:89). The various proposals for a cultural axis identified common social theories to create the OCF, and the NIMH Group applied the OCF to test cases from “the four main ethnically identified minorities in the United States, that is African Americans, American Indians, Asian Americans, and Latinos or Hispanic Americans” (Mezzich 2008:90). From today’s vantage point, re-reading these texts could lead to critiques that the concept of culture was presumed to be possessed by the patient, not by the doctor, and validated in the diagnostic assessment of ethnoracially minoritized individuals.

DSM-5 and the Expansion of the Culture Concept Beyond Minoritized Individuals

After DSM-IV’s publication, OCF use demonstrated varying conceptions of the culture concept in clinical practice. Some cultural psychiatrists from the NIMH Group advocated using the OCF with “culturally diverse individuals” in the United States, as described in the following manner: “The assessment of minority patients has additional layers of complexity when compared with assessment of nonminority patients, especially when the patient has a different cultural or ethnic background from the clinician… Clinicians need to be aware of their own cultural identity and their attitudes and beliefs toward ethnic minorities” (Lu, Lim, and Mezzich 2008:115). Although the article did not define who counted as a “culturally diverse individual,” references to “Eastern” vs. “Western” societies and “Eurocentric” vs. “multicultural” worldviews indicated that native-born, minoritized ethnoracial patients were assumed to be culturally diverse compared to “nonminority patients.” However, cultural psychiatrists outside of the United States applied the cultural concept to immigrants and refugees Even though just two participants from the NIMH Group resided outside North America (Littlewood 1992), cultural psychiatrists in Canada (Kirmayer et al. 2003), the Netherlands (Rohlof 2008), and Sweden (Bäärnhielm 2008) developed OCF-based interviews to address cultural issues in the diagnostic assessments of patients who presented to mental health clinics from newer patterns of migration.

At the same time, some cultural psychologists and psychiatrists challenged the minoritization of the cultural concept. In an APA publication titled A Research Agenda for DSM-V—a collection of white papers produced in partnership between the APA and NIMH—cultural mental health experts from psychiatry, psychology, and anthropology wrote, “DSM-IV still did not acknowledge the dynamic role of culture, intricately tied to the social world of the patient. It also tended to ‘exoticize’ the cultural approach by ascribing it only to ethnic minorities. The normality-psychopathology boundaries entail cultural thresholds for all clinical populations” (Alarcón et al. 2002:222). These authors called for a single format of the OCF to ease clinical use: “The standardization of all or selected components of the CF (and an inherent need to quantify them) to be used in culturally based measures of clinical severity, quality of life, or personal or group identity is a desirable development” (Alarcón et al. 2002:238).

The revision from DSM-IV to DSM-IV-TR did not change the OCF or its culture concept. Revisions were only to the “associated features” sections for cultural themes under some diagnoses, with most of the text remaining unchanged (First and Pincus 2002). During the revision from DSM-IV-TR into DSM-5, the DCCIS had an official status within the APA, unlike DSM-IV’s NIMH Group, with DCCIS members writings: “The Subgroup was charged by the DSM-5 Task Force with making recommendations on racial, ethnic, cultural, and contextual issues to the DSM-5 Work Groups related to differences in risk factors, precipitants, symptom presentations, prevalence, symptom severity, and course of illness” (Lewis-Fernández et al. 2014:132). As part of its work, the DCCIS focused on developments with the OCF:

The DCCIS undertook a critical review of the DSM-IV OCF. DCCIS participants prepared literature reviews on the whole OCF, each of its four domains, and on implementation questions raised by its use in clinical care (e.g., best practices; special populations in need of attention such as children, the elderly, or immigrants and refugees; format and content of interviews, protocols, and questionnaires operationalizing the Outline). They were also asked to recommend revisions to the OCF for DSM-5 (Lewis-Fernández et al. 2014:132)

The DCCIS standardized the collection of cultural information by creating the CFI: “More substantial changes related to making the OCF more user friendly by developing an interview to guide the process of clinical data collection. An initial 14-item interview was developed largely through previous question lists, interview protocols, and interviews that operationalized the OCF; most authors of these approaches were members of the DCCIS” (Lewis-Fernández et al. 2014:132). Hence, the DCCIS maintained the meaning-centered approach to the culture concept from DSM-IV by anchoring its literature review to the OCF. We did not explore alternatives to the meaning-centered tradition that the NIMH Group recommended. Whether this is a shortcoming, and why, merits debate.

One recommendation from the NIMH Group that the DCCIS successfully lobbied for in DSM-5 was to include definitions of culture, race, and ethnicity. A definition of culture—clearly focused on meanings—appears in the Introduction:

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 (American Psychiatric Association 2013:14).

A fuller definition in DSM-5’s section on Cultural Formulation de-minoritizes the culture concept and recognizes greater intragroup variation compared to DSM-IV:

Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience (American Psychiatric Association 2013:749).

A literature review prepared for DSM-5-TR of all publications on the CFI that reported original data from 2013 to 2020 identified one study that suggested changes to the OCF’s concept of culture (Aggarwal et al. 2020). A research group from India proposed an OCF-Revision (OCF-R) that would consist of five domains: (1) cultural identity of the patient, (2) illness explanatory model, (3) key social relationships, including with the clinician, (4) social, cultural, political, and economic contexts, and (5) an overall cultural assessment (Paralikar, Deshmukh, and Weiss 2020). The authors argued the field of psychiatry is historically less attentive to “the impact of social, cultural, political, and economic contexts affecting the lives of people in the world and the mental health of patients, apart from consideration of disorders defined by social or situational trauma, like post-traumatic stress disorder” (Paralikar, Deshmukh, and Weiss 2020:538). Drawing on clinicians using the CFI with patients in India, the authors wrote, “Although some of these issues were elicited by questions on cultural identity or the illness explanatory model in the CFI, they also suggest the additional value of asking directly about aspects of political, economic, communal, terrorist, and other potentially relevant contexts of life in patients’ worlds” (Paralikar, Deshmukh, and Weiss 2020:538). In an innovation from DSM-5, these researchers recommended that clinicians consider social forces outside of the patient–clinician relationship in their cultural formulations.

DSM-5-TR and the Incorporation of Social Structure in the Culture Concept

The televised murder of the Black American George Floyd on May 25, 2020 by police officers prompted the APA to examine structural racism which influenced the culture concept in DSM-5-TR. On May 31, 2020, the APA issued a press statement, quoting its President who said, “The horrific death of George Floyd has affected the mental well-being of everyone who has witnessed this senseless tragedy. When Americans are already suffering under the emotional toll of COVID-19, this blatant act of police brutality threatens to undermine the sense of stability of so many Americans” (American Psychiatric Association 2020b). In the same statement, the APA’s CEO and Medical Director said that Floyd’s death was an example of enduring racial disparities: “Centuries of systemic and institutional racism toward Black Americans has led to decreased access to health care and multiple adverse health outcomes—as recently seen during the COVID-19 pandemic—in addition to anxiety and lower life-expectancy. We need to fight racial inequalities and discrimination that are life-threating to so many Black Americans” (American Psychiatric Association 2020b). Two weeks later, the APA issued a statement condemning systemic racism in the United States, declaring, “We must do more than speak out in the moment, we must act to ensure that systemic racism is exposed and eliminated throughout our country and its institutions” (American Psychiatric Association 2020c).

To demonstrate its commitment, the APA announced a Presidential Task Force to Address Structural Racism Throughout Psychiatry whose main charges were “providing education and resources on APA’s and psychiatry’s history regarding structural racism” and “explaining the current impact of structural racism on the mental health of our patients and colleagues” (American Psychiatric Association 2020d). As an example of how cultural forces outside of psychiatry influence the culture of psychiatry, the APA’s President conceded that he was responding to nationwide demands for reform: “The history of the APA, going back to its very roots in the 1700s, is scarred with structural racism and racist ideas. While efforts have occurred over the years to rectify this problem, particularly by Black psychiatrists, as a field and organization we still have a very long way to go. I believe in this moment, when all Americans are seeing the murders and trauma of many Black Americans, as well as an upswell of activism and change” (American Psychiatric Association 2020d). On January 18, 2021, the APA’s Board of Trustees apologized for structural racism and misdiagnosis, stating: “Late 20th century psychiatrists commonly attributed their minority patients' frustrations to schizophrenia, while categorizing similar behaviors as ‘neuroticism’ in white patients… This reveals the basis for embedded discrimination within psychiatry” (American Psychiatric Association 2021).

In response, DSM-5-TR’s concept of culture includes greater attention to structural issues. Apart from a Cross-Cutting Review Committee on Cultural Issues that reviewed the text on cultural issues for each disorder, the APA’s “Ethnoracial Equity and Inclusion Work Group, composed of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices, reviewed references to race, ethnicity, and related concepts” (American Psychiatric Association 2022a). In the Introduction, a section titled “Cultural and Social Structural Issues” includes this paragraph:

Mental disorders are defined and recognized by clinicians and others in the context of local sociocultural and community norms and values. Cultural contexts shape the experience and expression of the symptoms, signs, behaviors, and thresholds of severity that constitute criteria for diagnosis. Sociocultural contexts also shape aspects of identity (such as ethnicity or race) that confer specific social positions and differentially expose individuals to social determinants of health, including mental health. These cultural elements are transmitted, revised, and recreated within families, communities, and other social systems and institutions and change over time. Diagnostic assessment should include how an individual’s experiences, symptoms, and behaviors differ from relevant sociocultural norms and lead to difficulties in adaptation in his or her current life context. Clinicians should also take into account how individuals’ clinical presentations are influenced by their position within social structures and hierarchies that shape exposure to adversity and access to resources (American Psychiatric Association 2022a)

DSM-5-TR’s definition of culture adds to DSM-5’s by including dimensions of health, illness, and social structure. All additions are underlined below:

Culture refers to systems of knowledge, concepts, values, norms, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, customs, and ways of understanding health and illness, as well as moral, political, economic, and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultural contexts, which they use to fashion their own identities and make sense of experience. This process of meaning-making derives from developmental and everyday social experiences in specific contexts, including health care, which may vary for each individual (American Psychiatric Association 2022a).

DSM-5-TR’s OCF includes these revised domains: (1) cultural identity of the individual, (2) cultural concepts of distress, (3) psychosocial stressors and cultural features of vulnerability and resilience, (4) cultural features of the relationship between the individual and the clinician, treatment team, and institution, and (5) overall cultural assessment (American Psychiatric Association 2022a). Twenty-eight years after DSM-IV’s publication, DSM-5-TR adopted the NIMH Group’s recommendation of “attention to social factors in the cultural considerations.”

It's not that the APA was previously ignorant of racism or structural issues. In 1969, 16 Black psychiatrists presented nine demands to the APA’s Board of Trustees, the first being “a Presidential Task Force of black psychiatrists to determine how the APA can become more relevant to the needs of black psychiatrists and the black community” (Geller 2020). Black psychiatrists proposed racism as a mental disorder for DSM-III and DSM-IV (Poussaint 2002). The DCCIS also underscored attention to culture, social structures, and the material environment in the DSM-IV-TR revision to DSM-5, arguing that “to maximize the validity and usefulness of diagnosis, these cultural/contextual elements need to be included in the design and implementation of our nosologies” (Lewis-Fernández and Aggarwal 2013:16). However, the APA took public action to address social structures and racism only after the death of George Floyd. Exactly why that historical moment triggered institutional reform awaits further research.

Future Directions for the Culture Concept in DSM Revisions

This article has traced the evolution of the culture concept in the OCF and CFI by examining official APA texts and scholarship in anthropology and psychiatry during the DSM-IV, DSM-5, and DSM-5-TR revisions. This evolution shows how DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. Even so, studies from Denmark and Mexico have shown that local cultural categories developed in the CFI face challenges when conceptions of culture are not uniform around the world. The death of George Floyd and calls for social justice in 2020 against structural racism accelerated the inclusion of structural factors in the culture concept for DSM-5-TR who consideration began nearly a decade earlier. This analysis shows how the culture concept in DSM revisions exemplifies an ongoing historical tension within cultural psychiatry of adopting a universalist psychological paradigm to affirm our common humanity after the extreme violence of World War II while retaining scholarly interests from the comparative psychiatry of the colonial period that reify cultural, racial, and ethnic differences in the clinical encounter (Antić 2021).

Clinicians who are skeptical of the social sciences could ask why they should understand the anthropological theories upon which the OCF and CFI’s culture concepts are based. One response is that the working model of culture affects the practice of cultural formulation. In critiquing biomedicine, Roland Littlewood (1996) writes, “In its attempt to become recognised as a purely naturalistic science, independent of the particular moral values in which it has developed, Western medicine has played down the social relationship between patient and doctor” (p. 245). In his view, the clinical encounter is inherently hierarchical as the clinician produces authoritative meanings: “Pathology is just one possible grid and one which carries with it a particular set of assumptions about normality and abnormality which explicitly ignores consideration of power and of the context of observation” (p. 259). This insight is reflected in the dominant model of culture conflict that scrutinizes how the patient ascribes qualities to the clinician, and vice-versa, through dynamics of transference and countertransference based on each’s cultural identity (Comas-Díaz and Jacobsen 1991) without exploring how they interrelate.

An alternate model does not conceptualize culture as solely possessed by the patient or through conflict with clinicians, but as an intersubjective process. Within the NIMH Group, some members whose viewpoints were not adopted in DSM-IV wrote, “Culture [i]s a moral process of interpretation and collective experience, composed of many voices, created by and, in turn, creator of social action, and located not in the minds of people, but between people, in the medium of intersubjective engagements that spread through the social world of families, work settings, networks, and whole communities” (Lewis-Fernández and Kleinman 1995:434). Since then, others have shown that the patient–clinician dyad mobilizes the identities of the patient and the clinician to constitute an intersubjective field through which meanings, values, and practices are exchanged in working through similarities and differences (Aggarwal 2011). As Ockert Coetzee has written with colleagues, “In the world of cross-cultural clinical work, there are two discursive poles which are commonly evoked, explicitly or implicitly. The first is the pole of difference, where there is an emphasis on the supposed gulfs that separate people. The second is the pole of sameness, where there is an emphasis on shared humanity. Neither of these poles fully articulates the complexities of identification amongst people” (Coetzee, Adnams, and Swartz 2019:287). This similarity-difference interplay explains why patient narratives of identities and illness explanations can vary based on the clinician’s identity (Aggarwal 2012) and communication practices during interviews (Groleau and Kirmayer 2004). Intersubjectivity challenges a model of culture residing in the psyches of patients to investigate how the patient–clinician dyad produces meanings and practices that are specific in time and place, mediated through communication behaviors (Kirmayer 2006).

With this understanding, DSM-5-TR can situate clinicians in an intersubjective cultural formulation. DSM-5 did not specify a relationship between the OCF and CFI, noting only that, “The CFI is a brief semistructured interview for systematically assessing cultural factors in the clinical encounter that may be used with any individual. The CFI focuses on the individual's experience and the social contexts of the clinical problem” (American Psychiatric Association 2013:751). Consistent with the DCCIS’s goal to standardize cultural assessment for DSM-5, domains for clinicians became questions for patients. For instance, the DSM-IV’s OCF included a domain for clinicians to introspect on the patient–clinician relationship which became a CFI question by DSM-5: “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?” (American Psychiatric Association 2013). Consequently, the burden of reflecting on the relationship transferred from the clinician to the patient, the less powerful member in the dyad (Aggarwal et al. 2013). DSM-5 included an online “Supplementary Module” on the patient–clinician relationship for clinicians to ask themselves how information from the CFI influenced diagnostic assessment and treatment planning, but there are no studies on this module since 2013 (Aggarwal et al. 2020), raising doubts about its use. Given the APA’s response to structural racism, DSM-5-TR states in the Culture and Psychiatric Diagnosis section that, “Cultural formulation may be especially helpful for individuals who are affected by healthcare disparities driven by systemic disadvantage and discrimination” (American Psychiatric Association 2022a, b).

Insights from the social sciences suggest how clinicians can contemplate their own cultural practices from biomedicine in an intersubjective cultural formulation. Most cultural competence interventions assume that clinical activities are amenable to change and can close healthcare disparities (Willen and Carpenter-Song 2013) without questioning the culture of biomedicine itself (Carpenter-Song, Schwallie, and Longhofer 2007). In contrast, anthropologists have advised clinicians to see their work as fundamentally cultural, writing, “It is important to train clinicians to unpack the formative effect that the culture of biomedicine and institutions has on the most routine clinical practices—including bias, inappropriate and excessive use of advanced technology interventions, and, of course, stereotyping” (Kleinman and Benson 2006). Professional education teaches students how biomedicine constructs the human body and disease through cultural ways (Good 1994). These ways include speaking practices through interviewing techniques with patients and case presentations with colleagues, writing practices in medical documentation, and thinking practices that “edit out” irrelevant data, regardless of differences in institutional contexts (Good and Hannah 2018). From this perspective, the CFI and other assessments that elicit information from patients about illness explanations, social stressors and supports, significant relationships, and life contexts serves to “edit in” information that counters the neuroscientific reductionism of clinical training (Luhrmann 2000). An intersubjective cultural formulation expands beyond a limited function of collecting meanings from patients to see how clinician practices such as communicating, diagnosing, recommending treatments, and documentation are intersubjective engagements in work settings through which patients and clinicians negotiate similarities and differences.

Enacting an intersubjective conceptualization of culture in psychiatric assessment and diagnostic practice would necessitate changes to the very idea of cultural formulation. The OCF in DSM-5-TR includes a final domain of “Overall Cultural Assessment” with these instructions: “Summarize the implications of the components of the cultural formulation identified in earlier sections of the Outline for the differential diagnosis of mental disorders and other clinically relevant issues or problems, as well as appropriate management and treatment intervention” (American Psychiatric Association 2022a, b). Intersubjectivity would require clinicians to contemplate the interrelationships among their institutional setting, communication practices, and patient responses. One way to concretize this suggestion would be for clinicians to answer each question of the CFI Supplementary Module on the Patient–Clinician Relationship before completing the Overall Cultural Assessment, documenting how their answers relate to patient diagnostic and treatment planning. This module’s questions are reproduced below:

  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? (American Psychiatric Association 2013)

Some clinicians could argue that they too busy to complete cultural formulations (Lewis-Fernández 2009). The counterargument is that thorough medical documentation is not just an ethical prerogative, but a legal necessity. Medical records are legal documents, and all patient charts should contain information relevant to diagnosis and treatment, interpersonal boundaries, and treatment (non-)adherence (Lambert and Wertheimer 2013). The cultural formulation addresses these very elements. An intersubjective cultural formulation would demand that clinicians avoid perpetuating disparities in making diagnosis, suggesting referrals for care, and offering evidence-based treatments by defending choices in the medical record. Misdiagnosis and improper treatment decisions remain common causes for medical malpractice claims against mental health clinicians (Frierson and Joshi 2019). Documenting the rationale for ruling in/out diagnoses based on cultural factors, development of treatment plans based on patient treatment preferences, and referrals to services that target structural problems can mitigate malpractice risks. Training in cultural formulation should recommend that clinicians at all stages remain proficient in interpreting scholarship on disparities in diagnoses, referrals, and evidence-based treatments throughout their careers.

Accepting an intersubjective concept of culture could also lead the APA Task Force and its contributors to rethink other sections of the DSM that rely on prior conceptualizations that equate culture with ethnicity or race. The DSM text of certain disorders has “Culture-Related Diagnostic Issues.” For instance, this section for Specific Phobia notes, “In the United States, individuals of Asian and Latinx descent report lower prevalence of specific phobia than non-Latinx Whites and African Americans” (American Psychiatric Association 2022a, b). An intersubjective concept of culture would question whether differences in minoritized ethnoracial populations reflect a genuinely lower prevalence rate of symptoms or a lower report of symptoms based on clinician communication practices or institutional settings. Similarly, this section for Social Anxiety Disorder notes, “The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by social-evaluative concerns, fulfilling criteria for social anxiety disorder, which are associated with the fear that the individual makes other people uncomfortable (e.g., ‘My gaze upsets people so they look away and avoid me’), a fear that is at times experienced with delusional intensity” (American Psychiatric Association 2022a, b). Here, the syndrome appears to be referring to behaviors that relate to Japanese or Korean ethnicity or a community connected by a common language, not necessarily to culture. Future DSM revisions would benefit from not equating culture with race and ethnicity by critically reviewing Culture-Related Diagnostic Issues for each disorder.

Likewise, specifying how institutional and structural factors affect mental health conditions could prompt future DSM revisions to rethink culture-related risk and prognostic factors. Do such differences across populations reflect actual changes in the course of psychopathology or inequitable access to mental health services? The OCF and the CFI both call on clinicians to evaluate barriers to help seeking, and secondary data analyses in future DSM revisions should interpret culture-related risk and prognostic factors against known barriers across population subgroups. A DSM that aims to situate patients in sociocultural contexts would develop methodologies that address this question before ascribing differences in risk and prognostic factors to culture rather than to socioeconomic status, stigma, or other known social determinants of mental health.

These proposals are likely to invite criticisms. Social scientists may challenge it for downplaying structural and social determinants of health outside clinical settings (Metzl and Hansen 2014). Nonetheless, a structural assessment could complement an intersubjective cultural formulation, and future debates about the culture concept in DSMs should be diverse and inclusive of multiple viewpoints beyond the meaning-centered tradition in anthropology. Clinicians could also resist examining their practices given longstanding professional values of personal non-disclosure and social authority (Kleinman 1988), though the power of US clinicians has eroded in the past year. The 21st Century Cures Act of 2021 now mandates clinicians to rapidly share medical records with patients upon request, yielding unprecedented transparency to test results, medication lists, referral information, and clinical notes (Salmi, et al. 2021). More than the latest clinical evidence or social science theories, cultural forces outside of psychiatry could compel clinicians within the culture of psychiatry to inevitably examine their clinical practices, including how they define the cultural concept.