Important notice
Please note that the images, figures, and tables for this Review have not been added yet. We are actively working to digitise and include these materials from our past magazines.
Main content
Access to mental health care of refugees/migrants is a long-standing problem. This article puts the spotlight on a method which recognizes the role of cultural dimensions in the diagnosis and treatment of refugees and migrants with mental health complaints. The article draws on an interview with psychiatrist Hans Rohlof, one of the leading forces behind the development and promotion of the cultural interview in mental health, and a literature review.
Background
According to the World Health Report on mental health (2001) it is estimated that in the situations of armed conflicts throughout the world, “10% of the people who experience traumatic events will have serious mental health problems and another 10% will develop behavior that will hinder their ability to function effectively. The most common conditions are depression, anxiety and psychosomatic problems such as insomnia, or back and stomach aches”. The interest in how to deal with these conditions has grown, in part because of increasing numbers of asylum seekers in industrialized countries, with consequently an increasing pressure on the health services in those countries. One of the methods of dealing with mental health issues is the cultural interview, which aims to untangle cultural connotations in mental health, especially among refugee populations.
The Cultural Formulation Interview (CFI), or Cultural Interview (CI) is rooted in anthropological theories and insights. It is a method of considering and incorporating sociocultural issues into the clinical formulation. It explores the patient’s own expression and evaluation of symptoms and dysfunction, including his/her explanatory models or idioms of distress, whilst assessing them against the norms of the cultural reference group. The method also helps to identify treatment experiences and preferences – including alternative medicine and indigenous approaches – and to assess cultural factors related to psychosocial stressors, available social supports, and levels of function or disability. In addition, it is useful to recognize the role of family, religion and spirituality in providing emotional, instrumental, and informational support. ¹
The 1994 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) introduced the Outline for cultural formulation of diagnosis, which provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. For some years this Outline remained relatively obscure, in part because of its location deep in the appendix section of the Manual. ² This gradually changed with the development of practical tools. In 2000 a group from the Centrum ’45-de Vonk, spearheaded by Hans Rohlof, developed the first edition of a cultural (formulation) interview. ³ From there on the CFI found its way to a wider audience. Its first edition was published in 2002 and translated into English. ⁴ To illustrate, in the Netherlands some 25 institutions work with the cultural interview. In 2014 the CFI was included in the DSM-V.
Evidence-based
Since its introduction in the DSM-IV some 20 years ago, the effectiveness of the cultural formulation of diagnosis (CFD) has been subject to research. The study ‘Culture in Diagnostics of Refugees: the Cultural Formulation of Diagnosis’ looked into the use and effect of CFD. The authors found 112 research studies and 28 case histories, of which 9 qualitative and 7 quantitative studies were suitable for further analysis. The CFD was used in quite diverse populations, among them refugees. The qualitative studies propagated the use of the CFD, and recommended several improvements. The quantitative studies found difference in treatment effect and improvement of therapeutic competencies in therapists. Overall it showed that CFD is used successfully in diverse populations, though there are improvements to be made, such as recognizing the influence of culture (on the therapist and patient alike), and of discrimination and a possible distorting effect of using translators. ⁵
An evaluation of the Outline for Cultural Formulation of Diagnosis showed that although it provides a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning, its use has been inconsistent. Findings indicated that in a significant number of cases, language barriers and the cultural complexity of the cases, as well as discrimination, had prevented adequate access to mental health care. ⁶
A study by Kirmayer et al. (2011) in Canada addressed the challenges in recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. The authors suggest that these issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations. ⁷
Culture in the DSM-5
The plea for more attention to culture in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was heard. In its latest edition a more prominent place is reserved for cultural connotations in mental disorders and ways to operationalize their assessment in daily practice. Though the debate on the universal applicability of the criteria of the DSM has not stalled, what is certain is that the DSM offers a standardized classification system, useful for communication between professionals, epidemiological profiling, and for making political choices in mental health. ⁸,⁹ By using cultural formulation, patients feel encouraged to formulate their definition of the complaints, and to illustrate background and stress factors leading to the problem. The introduction of the cultural formulation interview in the DSM-5 is a logical step in this process. However, a CFI alone is not enough. The need remains for a categorical dimension system which reflects on perceptions of illness, behavioural aspects in dealing with sickness and health, and attention to cultural aspects in neuroscience. Most likely such a paradigm shift will need time, perhaps until the next revision of the DSM.
References
- APA (2006). Cultural Formulation: From the APA Practice Guideline for the Psychiatric Evaluation of Adults, 2nd Edition FOCUS 2006;4:11-11.
- http://focus.psychiatryonline.org/article.aspx?articleid=50403
- Centrum ’45-de Vonk is the national institute for specialist diagnostics and the treatment of people with complex psychotrauma complaints, often a result of persecution and/or war, or of repeated job-related violence. 60% of the patients are refugees from 45 different countries.
- Borra R, Van Dijk R, Rohlof H (Eds) (2002). Cultuur, classificatie en diagnose (2002) (in Dutch).
- Rohlof H et al. (2009). Use of the Cultural Formulation with Refugees. Transcultural Psychiatry, 46 (3): 487-505.); Rohlof J G B M, Knipscheer JW, Kleber, R J (2011). Culture in the Diagnostics of Refugees. European Journal of Psychotraumatology, Suppl 1, 42.; Rohlof H, Groen S, van Dijk R, Starmans R. Cultural formulation of diagnosis. Onderzoek en implementatie van een cultuursensitief instrument. Cultuur, Migratie, Gezondheid 2010; 7: 76-87 (in Dutch).
- Lewis-Fernández R, et al. (2012). Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5.
- Kirmayer L J et al. (2011). Common mental health problems in immigrants and refugees: General approach to the patient in primary care. Canadian Medical Association Journal, 183(12).
- De Jong J T V M (2012). DSM-5 en cultuur. In: Tijdschrift voor psychiatrie 54 (2012) 9 (in Dutch) and comments on De Jong’s essay: Rohlof J G B M (2012). Psychiatrische diagnostiek, het ‘Culturele Interview’ en de DSM-5. In: Tijdschrift voor psychiatrie 54 (2012) 9 (in Dutch).
- For example, what would be the use of diagnosing a post traumatic stress disorder (PTSD) in an African country which recently escaped from a gruesome civil war? What appears is that 80% of the population suffer from a PTSD while there are no means to treat such a large group, and other priorities prevail such as rebuilding the society. Is it useful to conclude a depression (following the DSM criteria) amongst people who are near starvation? In such situations, in these particular countries, other questions need to be asked such as which interventions gain the largest health outcomes. De Jong suggests a three-pronged approach of cultural formulation, a dimensional approach of personality disorders and further dimensional diagnostics. (See: De Jong J T V M (2012). DSM-5 en cultuur. In: Tijdschrift voor psychiatrie 54 (2012) 9 (in Dutch).