THE CULTURAL FORMULATION: A METHOD FOR ASSESSING …20cultural%20assessment.pdfCultural factors...

P1: GCP/LCT/GIR P2: GCRPsychiatric Quarterly [psaq] ph129-psaq-375280 September 18, 2002 16:15 Style file version June 4th, 2002

Psychiatric Quarterly, Vol. 73, No. 4, Winter 2002 ( C© 2002)

THE CULTURAL FORMULATION: A METHODFOR ASSESSING CULTURAL FACTORS

AFFECTING THE CLINICAL ENCOUNTER

Roberto Lewis-Fernandez, M.D.and Naelys Dıaz, M.S.W.

The growing cultural pluralism of US society requires clinicians to examine theimpact of cultural factors on psychiatric illness, including on symptom presenta-tion and help-seeking behavior. In order to render an accurate diagnosis acrosscultural boundaries and formulate treatment plans acceptable to the patient,clinicians need a systematic method for eliciting and evaluating cultural infor-mation in the clinical encounter. This article describes one such method, theCultural Formulation model, expanding on the guidelines published in DSM-IV.It consists of five components, assessing cultural identity, cultural explanationsof the illness, cultural factors related to the psychosocial environment and lev-els of functioning, cultural elements of the clinician–patient relationship, andthe overall impact of culture on diagnosis and care. We present a brief his-torical overview of the model and use a case scenario to illustrate each of its

Roberto Lewis-Fernandez, M.D., is an Assistant Professor of Clinical Psychiatry atColumbia University, a Lecturer on Social Medicine at Harvard University, and is theDirector of the Hispanic Treatment Program at NY State Psychiatric Institute, NewYork, NY.

Naelys Dıaz, M.S.W., is a Doctoral Candidate in Social Work at Fordham University.Address correspondence to Roberto Lewis-Fernandez, M.D., New York State Psychi-

atric Institute, Unit 69, 1051 Riverside Drive, New York, NY 10032; e-mail: [email protected].

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272 PSYCHIATRIC QUARTERLY

components and the substantial effect on illness course and treatment outcomeof implementing the model in clinical practice.

KEY WORDS: cultural formulation; diagnostic assessment; cultural psychiatry; popularsyndromes; Latinos.

As rising immigration causes industrialized societies to become evenmore culturally pluralistic and organized mental health services in de-veloping nations face the challenge of distributing care more broadly,psychiatrists will increasingly come in contact with a larger diversityof social groups (1). The evaluation of patients from disparate ethno-cultural backgrounds requires clinicians to assess the impact of cul-tural factors on all aspects of psychiatric illness, including symptompresentation and help-seeking behavior. In order to render an accuratediagnosis across cultural boundaries and formulate treatment plansacceptable to the patient and oftentimes the family, clinicians need amethod for eliciting and evaluating cultural information during theclinical encounter.

Standardizing the assessment method is particularly important in or-der to avoid systematic misjudgments of which the clinician is often un-aware. An example of this is the apparent clinician bias that results ina higher rate of misdiagnosis of paranoid schizophrenia among AfricanAmerican and Latino patients suffering from bipolar disorder or de-pression with psychotic features, compared to non-Latino Whites (2,3).In one key study, misdiagnosis by race was found to be related to“information variance,” differences in the amount of information thepredominantly White clinicians obtained from African American as op-posed to White patients, rather than race-specific discrepancies in theway diagnostic criteria were applied (“criterion variance”) (4). This sug-gests that standardizing the process of clinical information-gatheringwould reduce misdiagnosis.

Using a systematic method for assessing cultural contributions toillness presentation would also help the clinician diagnose culturallypatterned experiences of illness that are distinct from mainstream psy-chiatric diagnostic criteria. Many societies around the world have de-veloped folk mental health classification systems that are distinct fromUS psychiatric nosology (5,6). Patients from these societies and culturalbackgrounds often express distress and psychopathology less in ac-cord with US diagnostic categories than with their popular syndromes.The translation between popular and professional nosologies is oftencomplicated. Neurasthenia, for example, originally a US professional


ROBERTO LEWIS-FERNANDEZ AND NAELYS DIAZ 273

diagnosis that is no longer included in the DSM system but is retainedin ICD-10, is the most prevalent current (12-month) disorder amongChinese Americans in Los Angeles County (7). For US psychiatrists,however, it presents a diagnostic challenge, due to its partial overlapwith multiple diagnostic categories, including mood, anxiety, and so-matoform disorders (7,8).

Ataque de nervios (attacks of nerves), on which we will focus laterin this article, is another example of a popular category that presentsdiagnostic challenges for US psychiatrists. This Latino syndrome ischaracterized by paroxysms of intense emotionality, acute anxietysymptoms, and loss of control, often associated with dissociative expe-riences and occasionally with other- or self-directed aggressive behav-iors (9). It constitutes the second most prevalent psychopathologicalsyndrome in Puerto Rico and has a complex relationship with psychi-atric diagnoses (10). Mainly associated with mood and anxiety disor-ders, it also can occur in conjunction with dissociative disorders (11)and in individuals with impulse control, somatoform, or psychotic dis-orders. The existence of these popular syndromes and the need for acase-by-case translation into DSM-IV categories underscores the risksof not obtaining sufficient cultural information as part of the diagnosticassessment.

In order to deliver care that is culturally valid, therefore, cliniciansneed a method that systematically allows them to take culture intoaccount when conducting a clinical evaluation. One such method thathas been operationalized in recent years is the Cultural Formulation(CF) model. The CF model supplements the biopsychosocial approachby highlighting the effect of culture on the patient’s symptomatology,explanatory models of illness, help-seeking preferences, and outcomeexpectations (12–15). It is described in Appendix I of DSM-IV (16) andis recommended for implementation during the assessment phase ofevery clinical relationship.

The CF model is especially necessary when the clinician and the pa-tient do not share the same cultural background, since it is then thatparticular attention to cultural features can be most helpful in orient-ing the clinical intervention. It is important to remember, however, thateven persons sharing the same race or ethnicity can differ in their cul-tural backgrounds, as race and ethnic groups are culturally heteroge-nous (12,17). Implementation of the CF model when there is no ethnicdifference between patients and clinicians can still elicit very useful in-formation about culturally based values, norms, and behaviors—suchas about alternative health practices, physiological interpretations, orreligious beliefs—that may otherwise go unnoticed because the clinician



assumes that the patient is “just like me.” In addition, the CF modelshould not be construed for use mainly between majority clinicians andminority patients. Given the growing ethno-cultural pluralism of psy-chiatric residency programs in the US (including a high proportion ofInternational Medical Graduates), the existence of cultural differencesis becoming perhaps just as likely between majority patients and theirclinicians.

This article will present the Cultural Formulation model. The firstpart of the discussion will give a brief historical overview of the modeland its components. The second part will consist of a case scenario thatwill illustrate the purpose of each section of the model and its usefulnessin psychiatry and mental health in general.

HISTORICAL OVERVIEW AND COMPONENTS OF THECULTURAL FORMULATION MODEL

The contemporary version of the CF model dates from the process ofpreparing DSM-IV. Due in part to criticisms of insensitivity to culturalissues in DSM-III and DSM-III-R, the National Institute of MentalHealth supported the creation in 1991 of a Group on Culture and Di-agnosis. The main goal of this Group was to advise the DSM-IV TaskForce on how to make culture more central to the Manual. One of theways proposed by the Group was the development of a standard methodfor applying a cultural perspective to the clinical evaluation (15,18).

Early efforts focused on supplementing the five existing axes with asixth or “Cultural Axis.” However, this approach was soon abandoned astoo limiting, since at best it would only permit the use of a restricted listof socio-cultural labels which would be of little clinical significance (14).The Group aimed for a more thorough re-thinking by the clinician ofthe patient’s cultural picture and how it affects all five axes, as well asclinical elements not contemplated by the multi-axial structure, suchas help-seeking expectations, family and community views of the ill-ness and its outcome, and institutional pressures on the clinical en-counter. A key aim of the Group was to operationalize a method that,while standardized, still allowed for an individualized assessment ofcultural factors (15). This was based on the perspective that a person’scultural background is affected by the intersection of multiple socialinfluences—including those due to gender, class, race, sexual orienta-tion, etc.—and therefore would need to be described in individual ratherthan solely collective terms in order to avoid stereotyping (12).

The Group settled on a narrative format that follows a standard setof components. These are listed in Table 1. Every patient would have



TABLE 1Components of the Cultural Formulation

Cultural formulationsection Subheading

Cultural identity of theindividual

• Individual’s ethnic or cultural referencegroup(s)• Degree of involvement with both the culture

of origin and the host culture (for immigrantsand ethnic minorities)• Language abilities, use, and preference

(including multilingualism)Cultural explanations

of the individual’sillness

• Predominant idioms of distress throughwhich symptoms or the need for socialsupport are communicated•Meaning and perceived severity of the

individual’s symptoms in relation to norms ofthe cultural reference group(s)• Local illness categories used by the

individual’s family and community to identifythe condition• Perceived causes and explanatory models that

the individual and the reference group(s) useto explain the illness• Current preferences for and past experiences

with professional and popular sources of careCultural factors

related to psychosocialenvironment andlevels of functioning

• Culturally relevant interpretations of socialstressors, available social supports, and levelsof functioning and disability• Stresses in the local social environment• Role of religion and kin networks in providing

emotional, instrumental, and informationalsupport

Cultural elements of therelationship betweenthe individual andthe clinician

• Individual differences in culture and socialstatus between the individual and theclinician• Problems that these differences may cause in

diagnosis and treatment (e.g. difficulties ineliciting symptoms and understanding theircultural significance, in determining whethera behavior is normal or pathological, etc.)

Overall culturalassessment fordiagnosis and care

• Discussion of how cultural considerationsspecifically influence comprehensivediagnosis and care

Note. Summarized from DSM-IV, pp. 843–844.



his/her cultural background described in a brief text that incorporateseach of the listed elements. This Cultural Formulation is based on priorwork on the “mini clinical ethnography,” which sets out a brief anthropo-logical assessment of the cultural factors that are immediately relevantto the clinical situation (19,20).

In selecting a narrative model, the Group was consciously endors-ing the growing importance of the study of narrative in anthropologyand other social sciences, as well as echoing a tradition within mentalhealth assessment: the psychodynamic formulation (14). In medicinein general, the use of narrative accounts of illness goes beyond diag-nostic typologies to claim a different “truth” in the creation of a hu-manized account of suffering from the patient’s perspective that en-compasses a greater view of the social world than the purely diagnosticevaluation (19). The use of this technique can also account for the rolethat health institutions and practitioners have on the evolution of theperson’s illness and his/her perception and interpretation of it (21,22).This allows a reflexive stance on the clinician-patient interaction, inwhich the role of the practitioner in shaping the process of evaluation,including what is reported by the patient and what is perceived by theclinician, can be “painted back in.”

An outline of the Cultural Formulation was prepared and submittedto the DSM-IV Task Force. In addition, a field test was performed onpatients from four US ethnic minorities: African American, AmericanIndian, Asian American, and Latino. The results revealed that the CFmodel could be successfully applied to patients from different culturalbackgrounds. An edited version of the proposed text was published inAppendix I of DSM-IV (15).

As a result of its publication in DSM-IV, the Cultural Formulationhas begun to form part of the curricula of US psychiatry residencyprograms. Since 1996, the CF model has been the subject of a regularsection on clinical case studies in Culture, Medicine and Psychiatry (14),of whom the senior author is the section editor, and of a yearly course atthe Annual Meeting of the American Psychiatric Association. In 2001,the Cultural Psychiatry Committee of the Group for the Advancementof Psychiatry published a book on the CF model that includes a numberof case examples (12).

CULTURAL FORMULATION OF A CLINICAL CASE

The second part of this article summarizes a case study of an actualpatient (23) that illustrates the purpose of each of the componentsof the Cultural Formulation and the impact on treatment outcome of



implementing this model in clinical practice. In particular, the casehighlights some of the diagnostic complexities involved in assessingpatients reporting nervios (nerves) and ataques de nervios (attacks ofnerves), prevalent popular syndromes among Latinos. A brief summaryof the clinical history is followed by the cultural formulation of the case.Informed consent was obtained from the patient for description of thisclinical material.

Clinical History

A 49 year-old widowed Puerto Rican woman presented to an outpatientLatino Mental Health Clinic in New England after a 3-year history ofprolonged hospitalizations due to recurrent major depressive disorderwith diagnosed psychotic features and chronic impulsive suicidality.Except for brief periods of partial recovery lasting less then 2 weeks,the patient reported several years of chronic sadness, anhedonia, tear-fulness, psychomotor retardation, suicidality, guilty ruminations, de-creased sleep and appetite, interest, energy, and concentration. Shealso suffered from restlessness, “nervousness,” trembling, increasedstartle, anguish, and severe headaches. Patient’s “psychotic” diagnosiswas due to the following during her affective decompensations: hearingher name called when alone, glimpsing a darting shadow, and “feeling”someone behind her. Despite past traumas (physical abuse, husband’smurder) she denied many of the symptoms of posttraumatic stress dis-order. There was no history of substance abuse. Her first episode ofmajor depression dated from age 32 and had recurred at least oncebefore the current episode.

Patient was born in rural Puerto Rico and had a 5th grade education.Her father developed alcoholism while working as a seasonal agricul-tural migrant in the United States and was verbally abusive and physi-cally threatening to the patient’s mother when intoxicated. The patientdenied witnessing overt physical or sexual abuse or being the objectof childhood trauma, but did complain of her mother’s cold distance.Patient married at 16 and had 6 children, one of whom died of pneu-monia at 3 months of age. Husband also developed alcohol problemsand became physically and emotionally abusive towards her. After anescalation of his abuse, patient ended the marriage by migrating to theEastern United States at age 31 with the man who became her secondhusband. She left four of her children behind with relatives, a decisionthat resulted in her parents’ rejection. Five years later she returned toPuerto Rico after the murder of her second husband in a street fight.The son who had migrated with her to the US entered a residential



drug abuse program 11 years later, at which point she migrated to adifferent East Coast city at age 47 to be near her oldest son from whomshe felt estranged. Her conflicts with this son and her other childrenprecipitated her inpatient admissions.

Inpatient psychotherapy, antidepressants, and antipsychotics onlyproduced minor improvement of her depression and suicidality and nochange in her psychotic symptoms. After discharge to the outpatientLatino Clinic, her psychotic symptoms were reassessed as normativePuerto Rican spiritual expressions of demoralization and her molindonewas discontinued. While still on phenelzine during evaluation for familytherapy, the patient suffered an ataque de nervios in the midst of anargument with her son. During the ataque, which was characterized bydissociative symptoms (depersonalization, “numbness”), she attemptedan impulsive overdose with phenelzine. She required ICU treatmentand a brief in-patient stay, and was taken off all psychiatric medications.

Intensive psychotherapeutic management was instituted, initially in-cluding individual, family, and group modalities. Improved family rela-tions resulted in marked decrease in symptoms. Outpatient assessmentand psychotherapy revealed patient’s longstanding characterologicalsymptoms and she received a diagnosis of Borderline Personality Dis-order. She reduced her participation in treatment after a few months,preferring weekly supportive psychotherapy and monthly psychiatricvisits. These latter acted as a kind of supervision of her clinical pic-ture, since medications were not prescribed. Patient was followed offmedications for 8 years without recurrence of major depression or sui-cidality. She did develop periodic exacerbations of depressive, anxiety,dissociative, and somatization symptoms that did not meet specified di-agnostic criteria. Though she continued to perceive “shadows” and hearher name called when alone, these experiences produced only tempo-rary concern. There was never any evidence of formal thought disordernor loss of generalized reality orientation [Summarized from (23)].

Cultural Formulation

Cultural Identity

The section on Cultural Identity serves as an introduction to the rest ofthe Cultural Formulation. Its purpose is to identify for each patient theparticular mix of socio-cultural influences that has patterned his/herindividual cultural world. As stated earlier, cultures are experienceddifferently by different members according to subgroup characteris-tics such as gender, class, religion, race, and sexual orientation, among



other factors. This section of the formulation collects information onhow these various social factors impact the person’s cultural environ-ment in order to prevent overly general or stereotypical interpretationsof cultural influence (13). This section also permits assessment of theperson’s own sense of his/her ethno-cultural identity, particularly inrespect to other alternative identities; this takes on particular signifi-cance in settings of rapid cultural change or ethnic conflict, or amongmigrants or persons of multicultural heritage. At the conclusion of thissection, the formulation writer should have a sense of how the personfits against a specific cultural background. This serves as a prelude tounderstanding how his/her individual experience of the illness and itsmeanings and outcomes fit within that cultural context, which is thetopic of the rest of the CF model (12).

The following subsections are included within the general section onCultural Identity. For the purpose of illustrating its content, each sub-section begins with one key question regarding the case under discus-sion that summarizes the subsection topic. We will follow this formatfor every subsection throughout the article.

Reference Group. Within her overall group (Puerto Rican culture),which particular cultural subgroups form the relevant context for as-sessing this person?

A key influence on this patient’s cultural background is her statusas a rural person with limited formal education who migrated twiceto the US for a total of 13 years’ residence as part of the “circular”pattern of Puerto Rican migration that intensified in the 1960’s and70’s. The “circularity” of this migratory stream consists of recurrent“back and forth” moves between Puerto Rico and usually the East Coastof the United States in search of better economic and health care op-portunities and in order to reestablish family and cultural links (24).Like many of these migrants, she was only mildly acculturated despitethis extended stay, given her periodic returns to her culture of originand the barriers to integration into the US mainstream for personsof her ethnic, class, and educational background caused by chronicunemployment and limited housing options outside of encapsulatedLatino neighborhoods (25). Her self-identity remained that of an Is-land Puerto Rican, despite her migratory experience. In effect, thispatient had retained most of the traditional views of illness from herrural background despite several years of residence in US urbansettings.

In this subsection it is also important to understand the patient’s mi-gratory process in the context of her former experience in Puerto Rico



and the reasons for her migration (13). Because her initial migration oc-curred in order to escape her husband’s physical abuse, and involved aprolonged separation from her children, this person’s migratory processis akin in some respects to that of a refugee, an unusual status amonglow-income Puerto Rican migrants, who are usually motivated by eco-nomic reasons. Some of her subsequent psychiatric symptoms, such asher acute alienation, guilt, and suicidality, can be better understoodagainst this unusual migratory context.

Language. Does the patient have access to more than one languagefor expressing her illness-related experiences and obtaining care, and ifso, which language predominates?

Language assessment is an important element of the CF model be-cause language identifies and codifies a person’s experience, which canbe distorted in the process of translation. In the case of multilingualindividuals, the use of a secondary language may limit the ability to ob-tain an accurate history and reach a valid diagnosis, since emotionalityand cognition may be expressed differently in different languages. Forexample, an individual may appear more or less pathological dependingon the language of the evaluation (26).

This patient used Spanish predominantly in all her daily interac-tions. Her use of English was very rare and her fluency poor. This consti-tutes another sign of her limited participation in non-Latino US society.Although the in-patient unit employed interpreters regularly in thecare of the patient, it is likely that some of the limitations in their clini-cal assessment were related to difficulties in bridging the language gap,resulting in relatively shallow interpretations of her experience. For ex-ample, the cultural connotations for the Spanish terms that the patientused to express her distress, such as nervios (nerves), ataques (attacks),and celajes (glimpses or shadows, understood by the staff as visual hal-lucinations), appear to have been lost or distorted during the translationprocess.

Cultural Factors in Development. Are there features of the patient’schildhood development that should be placed in a specific cultural con-text in order to be properly understood?

Locating childhood development within a cultural context can helpclarify the contribution of environmental factors to personality charac-teristics (12). Experience is made meaningful and incorporated as en-during personal attributes partly in response to its perceived normalityand collective interpretation. Factors that influence personality devel-opment and that vary across cultures include, among others: gender



roles, relational characteristics within the family and roles within thefamily constellation, socialization experiences, and social valuation ofemotional expression (27,28).

In this case, the patient’s childhood contacts were limited to her ex-tended kin group, given the rural isolation of her family compound andher early school termination. This may have intensified the negativeimpact on her personality development of her father’s disruptive andabusive behavior and her mother’s affective distance despite the statedabsence of witnessed or experienced physical or sexual abuse duringchildhood. These personality patterns were probably also reinforcedby later adult episodes of physical abuse and traumatic loss. Anothersociocultural feature of the patient’s early socialization that appearsto have influenced her later symptomatology relates to her role as aparentified child who was removed from elementary school in order tohelp raise her younger siblings. Though not an uncommon practice inthe patient’s cultural reference group, this seems to have determined aparticularly important element in her self-perception, as evidenced byher lifelong nickname within the family which refers to this maternalfunction. The loss of this culturally established role, through separa-tion and subsequent estrangement from her children, was the maincause of the patient’s affective decompensation. The partial resump-tion of this role through family therapy marked the beginning of herimprovement.

Involvement with Culture of Origin and Host Culture. How does un-derstanding a migrant like this patient in the context of her culture oforigin separately from the host culture reveal something about her as aperson and about her migration experience?

This subsection is primarily relevant to migrants. Its purpose is tocompare the individual’s involvement with the culture of origin, on theone hand, to his/her involvement with the host culture, on the other.By evaluating each attachment independently, the clinician can avoida zero-sum model of acculturation, which mistakenly assumes that asa person becomes more fluent in the new culture, he/she necessarilybecomes disconnected from his/her culture of origin (29). Instead, con-temporary acculturation models understand that, in a world where mul-ticulturality and geographical displacement are becoming increasinglyprevalent, multiple combinations of involvement are possible, such asthe alternative of developing a deep connection to both cultural envi-ronments (30). Finally, by establishing the migrant’s relative culturalattachments, the person’s cultural identity is rounded out, setting thestage for the other topics of the CF model.



This patient was predominantly connected to her culture of originand had limited contact with the host culture. She lived in a mainlyLatino neighborhood and traveled frequently to Puerto Rico, whereshe kept in close contact with several siblings; she had few friends,mostly Latinas, apart from her family. She was, however, able to ma-neuver some aspects of United States urban life well, such as obtain-ing elderly subsidized housing (though only in her 50’s) and disabilitybenefits.

Cultural Explanations of the Illness

The heart of the Cultural Formulation is this second section, whichexamines the cultural factors that affect the experience and interpre-tation of illness, as understood by the patient, the family, and the socialnetwork. These cultural factors exert a deeper influence than just cov-ering over an unchanging reality with curious cultural explanations.They instead help to create the illness experience by affecting cogni-tive, bodily, and interpersonal aspects of disease, including by helpingto shape symptom presentations, perceived etiologies, severity attri-butions, treatment choices, and outcome expectations (6,31). In partic-ular, explicit cultural analysis is required for accurate assessment ofthe severity of the presenting problems, since patients’ attributions ofseverity are acutely impacted by cultural interpretations. Finally, ad-herence to clinicians’ recommendations may be compromised withoutcareful attention to patients’ cultural views of treatment. In this re-spect, it may also be necessary to account for the views of key relativesor members of the larger social network (32).

Idioms of Distress and Local Illness Categories. How do cultural fac-tors affect the way this person experiences and understands her distress,including the specific shape of the presenting symptoms and the waythey are clustered?

Cross-cultural research reveals the existence of multiple overall per-spectives on distress—ways in which to experience, understand, anddescribe it—that are so comprehensive that they seem akin to differ-ent languages of suffering rather than specific syndromes. The term“idioms of distress” is used to denote these different languages of expe-rience (33). Examples of idioms are: the tendency to somatize suffering,or to psychologize it; experiencing interpersonal problems or physicalillness as forms of possession; attributing illness to the impact of suffer-ing on the anatomical “nerves”; or describing distress in terms of “fate,”or as a kind of “spiritual test” (16).



In addition to these general forms, cultures have also evolved morespecific illness categories or syndromes, assembled according to alter-native systems of causation. The organizing principle can be a rela-tively invariant collections of symptoms, a perceived common etiology,or a shared response to treatment (5). One of the essential tasks of aCultural Formulation is to discover the idioms of distress and the ill-ness categories that are evoked by the patient’s presentation. Oftenthe patient is not fully conscious of the categories he/she is referenc-ing, and yet may be acutely aware of the dissonance between his/herunderstandings and those of the clinician.

In this case, the patient’s illness was described by herself and her com-munity as nervios (nerves) and ataques de nervios (attacks of nerves).Patient’s view of her nervios was typical of many traditional PuertoRicans, for whom it is an idiom of distress describing a vulnerability toexperiencing symptoms of depression, anxiety, dissociation, somatiza-tion and rarely psychosis or poor impulse control given interpersonalfrustrations (34). The idiom is held together conceptually by the cul-tural understanding that all its presentations reflect an “alteration,”acquired or inherited, of the nervous system, and specifically of theanatomical nerves. The patient had suffered from all the symptomsof nervios except psychosis. Her acute fit-like exacerbations of nerviosare known as ataques de nervios, and were characterized by parox-ysms of anxiety, rage, dissociation, and impulsive suicidality followedby depression and exhaustion in response to acute interpersonal con-flicts (9,11). In this patient’s case, nervios and ataques were associatedwith her character pathology, but many Puerto Ricans suffer from sim-ilar folk syndromes without showing characterological deficits, thoughthe exact relationship between these clinical conditions has not beenascertained.

Another critical aspect of her nervios was the high frequency anddistressing nature of the culturally specific perceptual distortions shereported (hearing voices, feeling presences, seeing shadows [known ascelajes; glimpses]). These experiences are very prevalent among PuertoRicans with and without nervios, but sufferers of ataques are markedlymore distressed by them (35). They probably represent culturally pat-terned signs of anxiety or emotional distress determined by a person’sdissociative capacity. In the patient’s case, these experiences were mis-taken for psychotic symptoms by her inpatient clinicians. As such, dis-cussion of these symptoms in the Cultural Formulation straddles thissubsection and the next, as they constitute culturally specific idioms ofdistress whose interpretation can affect the perceived severity of thepresenting complaints.



Meaning and Severity of Symptoms in Relation to Cultural Norms.How does taking her cultural background into account affect the levelof pathology suggested by her presenting symptoms and their meaningas a form of communication in her interpersonal context?

This subsection is devoted to a careful assessment of the level ofseverity implied by the person’s symptoms, as well as to discussion ofthe role of the illness as a form of interpersonal communication that isinterpreted by others in the social network. It is essential that culturalnorms be considered when assessing the clinical severity of specific be-haviors, so as to avoid two erroneous extremes: overpathologizing whatis normative in a cultural group, or ascribing to normal behavior what isconsidered pathological in that culture (13,36). Whether what is at is-sue is the normal degree of individuation of an 18 year-old in relation tohis/her parents, or the potential delusionality of a person who ascribeshis/her symptoms to a supernatural etiology, some knowledge of localbehavioral norms is essential to the process of diagnosis. The fact thatdifferent subgroups within a larger cultural setting may interpret thesebehaviors differently complicates the process of assessment and forcesan individualized evaluation of cultural factors in each case.

In addition, illness expressions convey a range of meanings to othersin the social network. Which set of meanings is imputed by the com-munity actually has an impact on the patient’s course, both through in-terpersonal interactions that promote improvement or pathology andthrough concrete levels of assistance or rejection. The cross-culturalliterature on the contribution of expressed emotion to the course ofschizophrenia represents a well-developed example of this issue (37).

In this patient’s case, her symptoms at the time of presentation wereseen by her community to reflect a severe form of nervios because theycould precipitate rage and dissociation ataques with impulsive suici-dality and because they had “penetrated deeply,” causing her characterpathology. As opposed to her outpatient clinicians, who saw her charac-ter problems as preceding and partly determining her Axis I disorders,the patient’s social network understood her characterological symptomsas a consequence of her nervios, rather than as a cause (i.e., a form ofbitterness due to her continued suffering), and thus as a sign of nerviosseverity. In another discrepancy between the social network and theclinical team, the patient’s inpatient clinicians judged her perceptualdistortions to be much more severe than her community, understandingthem as signs of psychosis rather than minor elements of her overallcondition.

Further, the expectation of her interpersonal network was that thepatient actively ward against any worsening of her character pathology



by “controlling” her needs and desires and focusing on the needs ofothers, such as her children. The community thus validated the pa-tient’s understanding that reestablishing positive affective links withher family would improve the outcome of her nervios. Her achievementof this goal, as well as her coming off psychiatric medications and pre-venting further ataques, were considered signs of improvement. Thepatient’s children, however, initially rejected the patient’s and the com-munity’s understanding that her character pathology stemmed fromher nervios and ataques, attributing it instead to manipulative ploysaimed at deflecting their justified anger due to what they perceived asher neglectful parenting. Therapy helped to bridge these conflicting in-terpretations, but several of her children always retained the sense thatthe patient’s personality conflicts exceeded the norm even for nervios.

Perceived Causes and Explanatory Models. How is her clinical man-agement affected by knowing about her culturally based etiologicalattributions, her understandings of pathophysiology, and her hopes andconcerns about the course of the illness?

This subsection focuses on the patient’s views on how the illness“works”: what caused it; why did it present now and in this way; how is itaffecting the person; what would happen if it was not treated; and whatare the possible outcomes even with treatment? (12,38). This subsec-tion, like the next one on help-seeking to which it is closely linked, is es-pecially important during the process of enlisting the patient’s and thefamily’s adherence to the clinician’s recommendations. Patients rarelypursue treatments for long that run counter to their primary etiologicalunderstandings. Cultural attributions of causation actually vary widelyacross societies, from biological to spiritual etiologies, and from dras-tically individual, internal views to social and even cosmological inter-pretations (39). Often, there are a mix of attributions, at times partlyor wholly contradictory within one person or across the patient’s so-cial network. Treatment may thus involve negotiating the appearanceof these various perspectives and bringing them into some coherentstrategy (19).

At first, the patient saw her condition fundamentally as a medicalproblem caused by an “alteration” of her nervous system due to thesuffering produced by chronically unresolved family conflicts. Primaryamong these were the physical abuse by her husband, the parentalrejection, and her separation from several of her children during mostof their childhood, which led to their ongoing anger toward her. This is atypical traditional Puerto Rican interpretation of the impact of chronicsuffering on the “nerves.” If untreated, the patient feared that she would



become chronically psychotic (“loca”; crazy), given her limited ability, byherself, to “control” her symptoms, particularly her anger and grief (40).

Over time, however, medical treatment without family reconciliationwas likewise experienced as insufficient. The traditional link betweennervous ailments and past stressors served the outpatient clinicians asan entry point for discussing her interpersonal history, including theconflict with her children. One important function of her caregivers be-came that of contributing medical authority to the patient’s claims forfilial support. In that sense, the interpersonal element in her systemof etiological attributions grew to supersede the more physiological as-pects of her explanatory model. Her ongoing participation in treatmentwas attained in large measure by the growing confluence of this modelwith that of her providers, who also saw her problematic family rela-tionships as a main cause of her illness. In fact, clinicians’ success in en-listing family support for the patient became proof of their therapeuticvalue.

A secondary element of her explanatory model was the notion thather nervios illness produced a kind of spiritual “weakness,” which led tothe irruption of distressing spiritual visitations, perhaps by deceasedrelatives, which were experienced as perceptual distortions. This aspectof her model was never primary nor fully worked out, yet it initiallydisrupted her care, as it led to a diagnosis of psychosis by the inpatientteam. Even when improved, however, the patient remained leery ofthese experiences, preferring to pay them minimal attention.

Help-Seeking Experiences and Plans. How does the patient’s cul-tural identity help explain her past help-seeking choices and expecta-tions about current and future forms of assistance and treatment?

This subsection is closely linked to the previous one, as individualsusually seek out caregivers who offer assistance in ways that matchtheir explanatory models (13,19). Patients’ help-seeking choices actu-ally tend to follow “pathways” of care which are partly determinedby psychosocial and cultural forces. One expression of this is the waycultural perceptions and interpretations of illness affect not only thedecision whether and when to seek formal care (as opposed to beingself-reliant or asking for help from the immediate social network), butalso the type of treatment that is considered to be adequate and effec-tive (41). As with etiological attributions, help-seeking pathways canalso be quite complex, with multiple forms of care being accessed atonce, or in apparently contradictory ways.

During her early bouts of depression, which were acute but brief andoccurred years before the current presentation, the patient did not seek



ongoing medical care, relying only on rare emergency room visits. Atthe time, she felt her life traumas had not yet permanently “altered” hernervous system, and she relied mostly on her limited social network andon home remedies, such as herbal teas. Early on during her current pre-sentation, however, having come to see her condition as a physiologicalreaction to her interpersonal problems, she sought help first from pri-mary care internists. They in turn referred her to inpatient psychiatriccare, which the patient always understood as being sent to the medicalspecialists of the nervous system (“the doctors for nervios”). This wasa fortunate reframing of her treatment, since an alternative and fairlycommon interpretation in her cultural group could have been to rejectthe psychiatric referral as a sign that the clinicians mistakenly thoughtthat she was losing her mind. Over time, she accepted some forms ofmental health treatment but refused others, due to a mixture of cul-tural and personality characteristics. Family therapy, for example, mether view that an improved relationship with her son would help her re-cover from her illness, and was enthusiastically accepted. Other formsof psychotherapy directed more at intrapsychic change, such as grouptherapy, met intense resistance. Day hospital care came to be experi-enced as relatively unfocused and off-the-mark; instead, patient soughtdaily visits with her daughter-in-law, where she could re-establish so-cialization skills with family members. Her view of nervios as a medicalcondition never fully disappeared. She felt best protected from relapseby periodic check-ups with a psychiatrist, even when no medicationswere prescribed; the ongoing decision not to medicate reassured herthat her condition remained stable. Interestingly, despite the view thather perceptual distortions were due to spiritual “weakness,” she neversought the help of folk healers, saying “I don’t believe in any of that.”This highlights the intra-ethnic variation in help-seeking pathways,since many Puerto Ricans seek the assistance of espiritistas and otherspiritual healers at some point during the course of their illness (42).

Cultural Factors Related to Psychosocial Environmentand Levels of Functioning

This section of the CF model allows the clinician to examine how culturepatterns some of the stressors patients are exposed to and their reac-tions to these situations; the social supports available to them; and thecontexts against which their levels of functioning should be measured.Among other stressors, this part of the assessment can be used to elicitpatients’ experiences of trauma and how they incorporate these eventsinto their ongoing interpersonal relationships.



Social Stressors. How does the patient’s cultural background clarifythe origin and impact of the stressors she experienced?

The main stressor affecting the patient at the time of her presentationwas her estrangement from all of her children, which contradicts tradi-tional values regarding an extended and close family centered arounda matriarch. The patient alternated between feeling that this situationwas unfair and that it was a deserved punishment for abandoning fourof her children in childhood. That decision, which she described as thehardest of her life, was influenced by several social and cultural fac-tors. These include: the existence at that time of very few nonfamilysupports for abused women in rural Puerto Rico; the emergence of mi-gration as a government-sponsored escape valve for a labor force maderedundant by rapid industrialization; her parents’ lack of support formarital separation, even in the case of physical abuse; a tradition inrural Puerto Rico of placing “extra” children in informal foster arrange-ments with close relatives; and the expectation by some new male sex-ual partners (the man who became the patient’s second husband) thatthey not be expected to maintain non-infant children from a previousmarriage.

Seen over the course of her lifetime, the patient’s stressors were se-vere, and included the family disruption caused by her father’s alco-holism, her husband’s physical abuse, the death of a child in infancy,the dispersion of her nuclear family and the consequent discord withher parents and children, difficulties in acculturation to the US, eth-nic discrimination, chronic poverty and unemployment, the murder ofher second husband, and her children’s substance abuse and subse-quent loss of child custody. These stressors were considered by the pa-tient and her community to be adequate explanation of her nerviosillness.

Social Supports. How does her cultural identity contribute to theamount, nature, and quality of her social supports?

As a “circular” migrant who engaged in several migratory cycles andfrequent trips to Puerto Rico, the patient’s supports beyond her son,daughter-in-law, and caregivers consisted only of community drop-incenters and a few elderly Latinas. Her lack of supports probably con-tributed to the length of her hospitalizations, as her fear of going homeseemed to worsen her suicidality whenever discharge was discussed.Clinicians’ efforts to expand her support system through group ther-apy membership and psychiatric social clubs were hindered by hercharacter pathology. Most of the patient’s symptoms, including her sui-cidal ataques, may be understood as attempts to expand her social



support network by engaging the attention of family members as wellas professional caregivers. The patient always retained the belief thatin the face of her overwhelming social limitations and the original recal-citrance of her children, only the full expression of her symptomatologycould have produced a positive outcome.

Levels of Functioning and Disability. How does the patient’s culturalenvironment affect her level of functioning and degree of impairment?

Prior to her improvement, the patient saw her illness as progressiveand without cure, and feared degeneration into permanent insanity,consistent with widespread cultural concerns about severe nervios. Asa result of treatment, she came to feel that her nervios had not pro-gressed as far as she had feared, but that she would always remainpermanently vulnerable to relapse if confronted with more stress thanshe could handle, especially in her family interactions. She interpretedthe intermittent appearance of anxiety and depressive symptoms assigns of ongoing nervios illness which entitled her to lifelong subsi-dized housing and financial support from the government. Her age andlimited formal education, job skills, and English fluency in any casenarrowed her employment opportunities considerably and contributedto her expectation of government support. Unfortunately, the absenceof organized activities such as work also hindered the developmentof a social network beyond her family, which may have helped to de-compress the patient’s dependence on a limited number of supportivecontacts.

Cultural Elements of the Clinician–Patient Relationship

This section allows the clinician to consider how his/her own role orinstitutional setting has affected the patient’s illness experience, in-cluding symptom expression and treatment response. The scientificemphases on objectivity and material reality sometimes cause psychia-trists to mistake their activity for that of invisible observers, who exertlittle effect on the situation observed. On the contrary, much clinicaland ethnographic research has described how patients’ symptom de-scriptions and etiological attributions are shaped across health caresettings in response to clinicians’ verbal and nonverbal elicitations andto individual and collective expectations of what the purpose and thenorms are for each kind of setting (38,43). What counts as good andbad outcomes also varies across therapeutic interactions, dependingon whether the patient and caregiver are focusing on symptoms, long-term morbidity and mortality, psychosocial functioning, interpersonal



relationships, existential adjustment, ecological integration, or spiri-tual well-being. The clinical encounter is always a negotiated experience(44) that in addition echoes a wider system of institutional relation-ships, such as the organization of health care services, the influence ofthird-party review, and pressures brought to bear by employers (22).The clinical relationship is also impacted by ethno-cultural clashes inthe society at large, requiring clinicians to examine their attitudes to-ward a patient’s ethnicity and culture and how these impact the thera-peutic encounter. This understanding can be helpful not only in termsof evaluating the role of cultural differences in the interpretation ofpatients’ presentations, but also in avoiding biases based on ethnicstereotypes or other aspects of cultural identity (13). The current sec-tion encourages a systematic reflection on these interactions.

In the case of this patient, her psychiatric care prior to her referralto the outpatient Latino Clinic was hindered by the inpatient unit’slack of cultural information on various aspects of her presentation thathave been outlined in this Formulation. In particular, the diagnosticprocess was limited by the absence of a culturally normative assess-ment of the patient’s character structure, which resulted in the overem-phasis of her Axis I symptoms and a missed diagnosis of BorderlinePersonality Disorder. Likewise, lack of information about the culturalcharacteristics of nervios and ataques led to the misinterpretation ofher perceptual distortions as psychotic symptoms, with consequencesfor the patient’s psychopharmacological treatment. Finally, the inpa-tient unit’s reliance on pharmacological rather than psychotherapeu-tic interventions was not fully consonant with the patient’s treatmentexpectations.

The lack of relevant cultural information contrasts with the unit’sattention to more purely ethnic issues, such as the frequent use ofSpanish interpreters to ensure the patient’s participation in themilieu, and the focus on “ethnic matching” (45), achieved by assign-ing a Latino psychiatry resident to her care. The emphasis on ethnicityalone rather than culture is a problematic characteristic of contempo-rary US psychiatry that can lead, as in this case, to therapeutic practicesthat only go partway toward eliciting the relevant points of differencein the patient’s presentation and treatment response (46). The use ofSpanish, for example, is absolutely necessary for assessing a non-English speaking Latina such as this patient, but is not sufficient asa culturally valid intervention; for that, therapeutic approaches basedon cultural information are also required. Ethnic matching does notguarantee access to this material, since persons from the same ethnicbackground can differ in terms of cultural experience and clinicians may



be influenced less by their culture of origin than by their professionalcontext.

Referral to an outpatient clinic with an explicitly cultural focus re-sulted in a more comprehensive evaluation for the patient, leading to aprocess of rediagnosis and to the implementation of psychotherapeuticinterventions more in accord with her expectations, with more success-ful clinical results.

Overall Cultural Assessment

The final section of the Cultural Formulation summarizes the informa-tion in the previous sections, focusing on cultural material that con-tributes to diagnosis and treatment. The role that cultural featureshave played in determining overall illness outcome are particularlyemphasized.

In this case, the overall assessment would mention that the patient’scultural identity is that of a rural Puerto Rican migrant with limitedformal education, who speaks Spanish exclusively and has only livedfor limited periods in the US, resulting in minimal acculturation. Herpsychopathology is expressed in the traditional Puerto Rican idioms ofnervios and ataques de nervios. She attributed the origin of these prob-lems and her relapsing course to multiple past stressors and traumas,and especially to unresolved conflicts with her children resulting fromher prolonged separation from them during childhood. In fact, her clini-cal condition did not improve until their affective breach was addressedin family therapy.

The patient’s initial inpatient treatment proved ineffective partlybecause of the misattribution of a psychotic label to her perceptualdistortions, which are normative idioms of distress for this culturalgroup. Misdiagnosis exposed patient to the potentially toxic effects ofantipsychotic medication and interfered with referral to family ther-apy. In addition, lack of cultural information also hindered the iden-tification of patient’s underlying Axis II pathology and obscured therelationship between her character disorder and her persistent Axis Isymptoms, including her chronic suicidality and its exacerbations inthe form of ataques. Pharmacologic treatment of the patient’s refrac-tory depression—dangerous anyway due to her impulsive suicidality—proved unnecessary once intensive family intervention was underway.Her remaining intermittent Axis I symptoms led to periodic distress,warranting NOS diagnoses. But the patient’s primary psychopathologyproved to be characterological, fulfilling criteria for BorderlinePersonality Disorder. Like many patients with this disorder, she



displayed recurrent dysphoria, though in her case she did not meetstrict criteria for Dysthymia. Unlike many Borderline patients, how-ever, her course over the subsequent 8 years was remarkably uneventfulafter her initial response to psychotherapy, perhaps reflecting culturalvariation in the treatment outcome of Borderline Personality Disorder.

CONCLUSION

In this article we have presented the Cultural Formulation (CF) modelfor clinical assessment, discussing its historical development and itscomponents as outlined in Appendix I of DSM-IV. We also illustratedthe application of the model with a case scenario of a Puerto Ricanwoman suffering from the Latino popular syndromes of nervios andataques whose care was markedly improved by the implementation ofa cultural evaluation such as the one outlined.

At a time in which the value of delivering culturally congruent careis increasingly being recognized and requirements for cultural assess-ment are being incorporated into treatment guidelines and professionaltraining curricula, the Cultural Formulation model represents one ofthe main existing methods for attaining and implementing a culturallyvalid approach to care (12). Regular use of the model teaches cliniciansnot only how to elicit culturally relevant clinical material, but also ex-poses them over time to the content of many cultural perspectives fromdiverse patients and their families, thus increasing caregivers’ fund ofcultural knowledge.

The growing cultural pluralism of US society requires that the CFmodel become an essential aspect of every clinical training program.The “long version” of the model, such as the one described in this arti-cle, can be taught during clinical supervision as part of comprehensivepatient assessments. This is the format we are using during the out-patient year (PGY-III) at the Adult Psychiatry Residency Program ofColumbia University and NY State Psychiatric Institute. The “shortversion” of the model, similar to the Overall Cultural Assessment sec-tion of the full Formulation, could then be used for all new evaluationsor comprehensive reassessments of refractory patients once proficiencyin the full CF model is established.

It is also imperative that research be conducted on the effectivenessof the Cultural Formulation as a method for improving treatment out-comes, including assessment of its cost-benefit ratio. Findings from thisresearch will help clarify the contribution of the CF model to clinicalcare, and prepare the way for its role in DSM-V.



ACKNOWLEDGMENTS

Dr. Lewis-Fernandez was supported by a National Institute of Men-tal Health (NIMH) Under-represented Minority Research Supplement(5 R10 MH55165). Ms. Dıaz was supported by NIMH grant T32MH20074 to the Center for Hispanic Mental Health Research atFordham University.

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