Skip to main content
SpringerLink
Log in

The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter

  • Published:
Psychiatric Quarterly Aims and scope Submit manuscript

Abstract

The growing cultural pluralism of US society requires clinicians to examine the impact of cultural factors on psychiatric illness, including on symptom presentation and help-seeking behavior. In order to render an accurate diagnosis across cultural boundaries and formulate treatment plans acceptable to the patient, clinicians need a systematic method for eliciting and evaluating cultural information in the clinical encounter. This article describes one such method, the Cultural Formulation model, expanding on the guidelines published in DSM-IV. It consists of five components, assessing cultural identity, cultural explanations of the illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the clinician–patient relationship, and the overall impact of culture on diagnosis and care. We present a brief historical overview of the model and use a case scenario to illustrate each of its components and the substantial effect on illness course and treatment outcome of implementing the model in clinical practice.

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

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

REFERENCES

  1. Desjarlais R, Eisenberg L, Good B, Kleinman A: World Mental Health: Problems and Priorities in Low-Income Countries, New York, Oxford University Press, 1995.

    Google Scholar 

  2. Mukherjee S, Shukla S, Woodle J, Rosen AM, Olante S: Misdiagnosis of chizophrenia in bipolar patients: A multiethnic comparison. American Journal of Psychiatry 140:1571-1574, 1983.

    Google Scholar 

  3. Strakowski SM, Flaum M, Amador X, Bracha HS, Pandurangi AK, Robinson D, Tohen M: Racial differences in the diagnosis of psychosis. Schizophrenia Research 21:117-124, 1996.

    Google Scholar 

  4. Strakowski SM, Hawkins JM, Keck PE, McElroy SL, West SA, Bourne ML, Sax KW, Tugrul MC: The effects of race and information variance on disagreement between psychiatric emergency service and research diagnoses in first-episode psychosis. Journal of Clinical Psychiatry 58:457-463, 1997.

    Google Scholar 

  5. Good BJ, Delvecchio-Good M-J: Toward a meaning-centered analysis of popular illness categories: “Fright-illness” and “heart distress” in Iran. In: Marsella AJ, White GM, eds., Cultural Conceptions of Mental Health and Therapy, Dordrecht, D. Reidel, 1982, pp. 141-166.

    Google Scholar 

  6. Kleinman A: Rethinking Psychiatry: From Cultural Category to Personal Experience, New York, The Free Press, 1988.

    Google Scholar 

  7. Zheng YP, Lin KM, Takeuchi D, Kuralski KS, Wang YX, Cheung F: An epidemiological study of neurasthenia in Chinese-Americans in Los Angeles. Comprehensive Psychiatry 38:249-259, 1997.

    Google Scholar 

  8. Lee S, Wing Y, Chan C, Lee AM, Lee DTS, Chen CN, Lin KM, Weiss MG: Psychiatric morbidity and illness experience of primary care patients with chronic fatigue in Hong Kong. American Journal of Psychiatry 157:380-384, 2000.

    Google Scholar 

  9. Guarnaccia PJ, Rivera M, Franco F, Neighbors C: The experiences of ataques de nervios: Towards an anthropology of emotions in Puerto Rico. Culture, Medicine and Psychiatry 20:343-367, 1996.

    Google Scholar 

  10. Guarnaccia PJ, Canino G, Rubio-Stipec M, Bravo M: The prevalence of ataques de nervios in the Puerto Rico Disaster Study. Journal of Nervous and Mental Disease 181:157-165, 1993.

    Google Scholar 

  11. Lewis-Fernández R, Garrido P, Bennasar M, Parrilla E, Laria AJ, Ma G, Petkova E: Dissociation, childhood trauma, and ataque de nervios among Puerto Rican psychiatric outpatients. American Journal of Psychiatry, 159:1603-1605, 2002.

    Google Scholar 

  12. Group for the Advancement of Psychiatry Committee on Cultural Psychiatry: Cultural Assessment in Clinical Psychiatry, Washington, D.C., American Psychiatric Publishing, 2001.

    Google Scholar 

  13. Lu FG, Lim RF, Mezzich JE: Issues in the assessment and diagnosis of culturally diverse individuals. In: Oldham JM, Riba MB, eds., Review of Psychiatry, Vol. 14, Washington, D.C., APA Press, 1995, pp. 477-510.

    Google Scholar 

  14. Lewis-Fernández R: Cultural formulation of psychiatric diagnosis. Culture, Medicine and Psychiatry 20:133-144, 1996.

    Google Scholar 

  15. Mezzich JE: Cultural formulation and comprehensive diagnosis: Clinical and research perspectives. Psychiatric Clinics of North America 18:649-657, 1995.

    Google Scholar 

  16. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Washington, D.C., 1994.

  17. Smedley A: “Race” and the construction of human identity. American Anthropologist 100:690-702, 1999.

    Google Scholar 

  18. Alarcón RD: Culture and psychiatric diagnosis: Impact on DSM-IV and ICD-10. Psychiatric Clinics of North America 18:449-465, 1995.

    Google Scholar 

  19. Kleinman A: The Illness Narratives: Suffering, Healing, and the Human Condition, New York, Basic Books, 1988.

    Google Scholar 

  20. Weiss M: Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural Psychiatry 34:235-263, 1997.

    Google Scholar 

  21. Saris JA: Telling stories: Life histories, illness narratives, and institutional landscapes. Culture, Medicine and Psychiatry 19:39-72, 1995.

    Google Scholar 

  22. Mechanic D: The experience and expression of distress: The study of illness behavior and medical utilization. In Mechanic D, ed., Handbook of Health, Health Care, and the Health Professions, New York, The Free Press, 1983, pp. 591-607.

    Google Scholar 

  23. Lewis-Fernández R: Diagnosis and treatment of nervios and ataques in a female Puerto Rican migrant. Culture, Medicine and Psychiatry 20:155-163, 1996.

    Google Scholar 

  24. Hernández-Cruz J: Migraci´on de retorno o circulaci´on de obreros boricuas? Revista de Ciencias Sociales 24:81-102, 1985.

    Google Scholar 

  25. Rodríguez CE: Puerto Ricans: Born in the U.S.A., Boulder, Westview Press, 1991.

    Google Scholar 

  26. Oquendo MA: Psychiatric evaluation and psychotherapy in the patient's second language. Psychiatric Services 47:614-618, 1996.

    Google Scholar 

  27. Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and Conceptual Interactions, New York, Wiley, 1998.

    Google Scholar 

  28. Lewis-Fernández R, Kleinman A: Culture, personality, and psychopathology. Journal of Abnormal Psychology 103:67-71, 1994.

    Google Scholar 

  29. Rogler LH, Cortés DE, Malgady RG: Acculturation and mental health status among Hispanics. American Psychologist 46:585-597, 1991.

    Google Scholar 

  30. Marín G, Gamba RJ: A new measurement of acculturation for Hispanics: The Bidimensional Acculturation Scale for Hispanics (BAS). Hispanic Journal of Behavioral Sciences 18:297-316, 1996.

    Google Scholar 

  31. Good BJ: Medicine, Rationality, and Experience: An Anthropological Perspective, Cambridge, Cambridge University Press, 1994.

    Google Scholar 

  32. McKinlay JB: Social network influences on morbid episodes and the career of help-seeking. In: Eisenberg L, Kleinman A, eds., The Relevance of Social Science for Medicine, Dordrecht, D. Reidel, 1981, pp. 77-107.

    Google Scholar 

  33. Nichter M: Idioms of distress: Alternatives in the expression of psychosocial distress: A case study from South India. Culture, Medicine and Psychiatry 5:379-408, 1981.

    Google Scholar 

  34. Guarnaccia PJ, Lewis-Fernández R, Rivera M: Towards a Puerto Rican popular nosology: Nervios and ataques de nervios. Culture, Medicine and Psychiatry, in press.

  35. Lewis-Fernández R, Canino G, Ramírez R, Febo V, Bravo M: Latino perspectives on mental health in primary care. In: Proceedings of the 49th Institute on Psychiatric Services, American Psychiatric Association, 1997, p. 142.

  36. L´opez SR: Patient variable biases in clinical judgment: Conceptual overview and methodological considerations. Psychological Bulletin 106:184-203, 1989.

    Google Scholar 

  37. Jenkins JH, Karno M: The meaning of expressed emotion: Theoretical issues raised by cross-cultural research. American Journal of Psychiatry 149:9-21, 1992.

    Google Scholar 

  38. Kleinman A: Patients and Healers in the Context of Culture, Berkeley, University of California Press, 1980.

    Google Scholar 

  39. Marsella AJ, White GM: Cultural Conceptions of Mental Health and Therapy, Dordrecht, D. Reidel, 1982.

    Google Scholar 

  40. Lewis-Fernández R: “That was not in me - I couldn't control myself”: Control, identity, and emotion in Puerto Rican communities [Spanish]. Revista de Ciencias Sociales 4:268-299, 1998.

    Google Scholar 

  41. Rogler LH, Cortés DE: Help-seeking pathways: A unifying concept in mental health care. American Journal of Psychiatry 150:554-561, 1993.

    Google Scholar 

  42. Garrison V: Doctor, espiritista or psychiatrist?: Health-seeking behavior in a Puerto Rican neighborhood of New York City. Medical Anthropology 1:65-191, 1977.

    Google Scholar 

  43. Good BJ, Delvecchio-Good M-J: The meaning of symptoms: A cultural hermeneutic model for clinical practice. In: Eisenberg L, Kleinman A, eds., The Relevance of Social Science for Medicine, Dordrecht, D. Reidel, 1980, pp. 165-196.

    Google Scholar 

  44. Lazare A, Eisenthal S, Wasserman L: The customer approach to patienthood. Archives of General Psychiatry 32:553-558, 1975.

    Google Scholar 

  45. Sue S, FujinoDC, Hu LT, Takeuchi DT, Zane NWS: Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical Psychology 59:533-540, 1991.

    Google Scholar 

  46. Whaley AL: Cultural mistrust: An important psychological construct for diagnosis and treatment of African Americans. Professional Psychology: Research and Practice 32:555-562, 2001.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Columbia University, USA

    Roberto Lewis-Fernández (Assistant Professor of Clinical Psychiatry)

  2. Harvard University, USA

    Roberto Lewis-Fernández (Assistant Professor of Clinical Psychiatry)

  3. Hispanic Treatment Program, NY State Psychiatric Institute, New York, New York

    Roberto Lewis-Fernández (Assistant Professor of Clinical Psychiatry)

  4. USA

    Naelys Díaz (Doctoral Candidate in Social Work)

Authors
  1. Roberto Lewis-Fernández
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naelys Díaz
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lewis-Fernández, R., Díaz, N. The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter. Psychiatr Q 73, 271–295 (2002). https://doi.org/10.1023/A:1020412000183

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1020412000183

Search

Navigation