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Cultural Formulation Interview (CFI)

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Cultural Formulation Interview (CFI)

Supplementary modules used to expand each CFI subtopic are noted in parentheses.

Name: Sabrina Hinajosa Age: 29 Sex: Female Date: Today

GUIDE TO INTERVIEWER INSTRUCTIONS TO THE INTERVIEWER ARE ITALICIZED.

The following questions aim to clarify key aspects of the presenting clinical problem from the point of view of the individual and other members of the individual’s social network (i.e., family, friends, or others involved in current problem). This includes the problem’s meaning, potential sources of help, and expectations for services.

INTRODUCTION FOR THE INDIVIDUAL:

I would like to understand the problems that bring you here so that I can help you more effectively. I want to know about your experience and ideas. I will ask some questions about what is going on and how you are dealing with it. Please remember there are no right or wrong answers.

CULTURAL DEFINITION OF THE PROBLEM

(Explanatory Model, Level of Functioning)

Elicit the individual’s view of core problems and key concerns.

Focus on the individual’s own way of understanding the problem.

Use the term, expression, or brief description elicited in question 1 to identify the problem in subsequent questions (e.g., “your conflict with your son”).

1. What brings you here today?

IF INDIVIDUAL GIVES FEW DETAILS OR ONLY MENTIONS SYMPTOMS OR A MEDICAL DIAGNOSIS, PROBE:

People often understand their problems in their own way, which may be similar to or different from how doctors describe the problem. How would you describe your problem?

I recently lost my mother-in-law to a heart attack in the process of evacuating from the hurricane. She was my rock. I was closer to her than my own mother. I am feeling completely overwhelmed and emotionally exhausted from everything we’ve been through in the past month, and I am just so sad and angry all the time.

Ask how individual frames the problem for members of the social network.

2. Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?

That I am a crappy daughter-in-law who didn’t see the signs and respond fast enough and that I was more concerned about my house being okay than supporting her.

Focus on the aspects of the problem that matter most to the individual.

3. What troubles you most about your problem?

That I can’t get her back.

CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT

CAUSES

(Explanatory Model, Social Network, Older Adults)

This question indicates the meaning of the condition for the individual, which may be relevant for clinical care.

4. Why do you think this is happening to you? What do you think are the causes of your [PROBLEM]?

I know rationally that there was nothing that could really be done, but I have a lot of self-blame. If I hadn’t have left her

Cultural Formulation Interview (CFI)

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home alone to go seal up my home and get my kids maybe she’d be here still. And, of course, there is the stupid hurricane.

Note that individuals may identify multiple causes, depending on the facet of the problem they are considering.

PROMPT FURTHER IF REQUIRED:

Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or many other causes.

Focus on the views of members of the individual’s social network. These may be diverse and vary from the individual’s.

5. What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?

Everyone says it was “just her time”. Even my husband. He thinks this was all God’s plan, including the hurricane. That just makes me thing God’s a jerk. Mostly everyone feels bad for us and says it was all just an unfortunate series of events. I know this is true but it is so infuriating to hear right now. I can’t handle it.

STRESSORS AND SUPPORTS

(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Cultural Identity, Older Adults, Coping and Help Seeking)

Elicit information on the individual’s life context, focusing on resources, social supports, and resilience. May also probe other supports (e.g., from co-workers, from participation in religion or spirituality).

6. Are there any kinds of support that make your [PROBLEM] better, such as support from family, friends, or others?

My kids are my main focus right now. They are just getting back to school and have lost their abuela. I want them to be okay. Being with them reminds me of her and makes me feel better.

Focus on stressful aspects of the individual’s environment. Can also probe, e.g., relationship problems, difficulties at work or school, or discrimination.

7. Are there any kinds of stresses that make your [PROBLEM] worse, such as difficulties with money, or family problems?

Yes, our house is still a wreck. We are back in there, but we haven’t been able to get flooring replaced and there is a ton of water damage. We didn’t have flood insurance and the house insurance doesn’t cover it. I have no idea how we are going to manage it all. Not to mention we just had to pay for my mother- in-law’s funeral. Our friends and family are trying to help, but it’s just a lot. Just thinking about it all makes me want to shut down.

ROLE OF CULTURAL IDENTITY

(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Older Adults, Children and Adolescents)

Sometimes, aspects of people’s background or identity can make their [PROBLEM] better or worse. By background or identity, I mean, for example, the communities you belong to, the languages you speak, where you or your family are from, your race or ethnic background, your gender or sexual orientation, or your faith or religion.

Ask the individual to reflect on the most salient elements

of his or her cultural identity. Use this information to tailor questions 9–10 as needed.

8. For you, what are the most important aspects of your background or

identity?

Cultural Formulation Interview (CFI)

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My husband is Mexican and we are very close to his family. They are all very tight-knit and love to celebrate everything all the time. They “adopted” me into their family when we started dating 12 years ago, and I’ve been one of them since. I would say that is my primary support network.

My husband is Catholic, but he doesn’t practice actively and I never converted. I was never much of anything growing up. My parents divorced when I was young and neither of them were very spiritual. I think my mom sort of believed in Buddhist principles but my dad was agnostic. Before Maria died, my husband and I were talking about how to raise our kids in faith since they are getting older, but I’m really struggling with the whole concept of God right now.

Elicit aspects of identity that make the problem better or worse.

Probe as needed (e.g., clinical worsening as a result of discrimination due to migration status, race/ethnicity, or sexual orientation).

9. Are there any aspects of your background or identity that make a difference to your [PROBLEM]?

It’s great to have a family who is so supportive and so close by. But Maria was the heart of the family. We are all lost without her and I don’t know how things will change without her here to keep us all together. I have a ton of fear around that.

Probe as needed (e.g., migration-related problems; conflict across generations or due to gender roles).

10. Are there any aspects of your background or identity that are causing other concerns or difficulties for you?

Maybe just my current anger at God. My husband really seeks comfort in prayer right now and it just ticks me off. We’ve fought about it a couple of times.

CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING

SELF-COPING

(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors)

Clarify self-coping for the problem. 11. Sometimes people have various ways of dealing with problems like [PROBLEM]. What have you done on your own to cope with your [PROBLEM]?

I’m here. I’m tired of crying and yelling all the time. I know something needs to change, so I’m here. Outside of that I don’t really do anything. I’m not a drinker, and I don’t really like to exercise. There just hasn’t really been time for TV or reading, and I don’t think I could focus on those anyway. Mostly I’ve just thrown myself into taking care of my kids and trying to shield them from everything.

PAST HELP SEEKING

(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)

Cultural Formulation Interview (CFI)

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

Elicit various sources of help (e.g., medical care, mental health treatment, support groups, work-based counseling, folk healing, religious or spiritual counseling, other forms of traditional or alternative healing).

Probe as needed (e.g., “What other sources of help have you used?”).

Clarify the individual’s experience and regard for previous help.

12. Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for your [PROBLEM]?

PROBE IF DOES NOT DESCRIBE USEFULNESS OF HELP RECEIVED:

I haven’t sought help for this. I mean, I’ve talked to some friends and family. They are the ones who recommended I come in, but nothing else really. I did come to counseling one other time in the past. I was raped five years ago while on a business trip. It turned my world upside down, and I ended up getting some help. I had to. It’s not the same thing, but I feel that same sense of being out of my own control now.

What types of help or treatment were most useful? Not useful?

The counseling was helpful at the time. I’m not sure I would have made it without it. I thought I was losing my mind and no ability to trust anyone, even my own husband. Of course, my mother in law helped a lot too. She always protected me like a daughter and made sure I was okay through that experience.

BARRIERS

(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)

Clarify the role of social barriers to help seeking, access

to care, and problems engaging in previous treatment.

Probe details as needed (e.g., “What got in the way?”).

13. Has anything prevented you from getting the help you need?

PROBE AS NEEDED:

For example, money, work or family commitments, stigma or discrimination, or lack of services that understand your language or background?

Time is the real issue. I don’t really have time for things like this with everything else going on. And, of course there is money. My husband says it is worth it, and I know I need it, but I hate to think I am costing us any more money when we need basic things like carpet in our house.

CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING

PREFERENCES

(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)

Clarify individual’s current perceived needs and expectations of help, broadly defined.

Probe if individual lists only one source of help (e.g., “What other kinds of help would be useful to you at this time?”).

Now let’s talk some more about the help you need.

14. What kinds of help do you think would be most useful to you at this time for your [PROBLEM]?

I wish I could turn back time and make it so this never happened. I know I can’t do that, but that is what I wish. Outside of that I just want to get through this, be able to take care of my kids, have a safe home to live in, not be so moody, and figure out how to survive without Maria.

Focus on the views of the social network regarding help seeking.

15. Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?

Cultural Formulation Interview (CFI)

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

No. I mean my husband wishes I would consider prayer or God. He keeps telling me that was important to his mom, and I know it was. But I can’t go there right now. Everyone else says I just need to give myself time, but I don’t even know what that means.

CLINICIAN-PATIENT RELATIONSHIP

(Clinician-Patient Relationship, Older Adults)

Elicit possible concerns about the clinic or the clinician- patient relationship, including perceived racism, language barriers, or cultural differences that may undermine goodwill, communication, or care delivery.

Probe details as needed (e.g., “In what way?”).

Address possible barriers to care or concerns about the clinic and the clinician-patient relationship raised previously.

Sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations.

16. Have you been concerned about this and is there anything that we can do to provide you with the care you need?

I don’t know. It all seems so arbitrary at this point. I mean my last counseling experience was good. I don’t think I would have survived without going. But I also went because I had a lot of support, especially from Maria. Without her this all feels somewhat pointless. I’m willing to come because I know I need the help and I know my girls need their mom to be okay. I guess I just need you not to ask me to pray or tell me it’s not my fault. I’m so tired of all of that. My last counselor was really good at holding me accountable, so I guess that’s good too. I need that. This is also the first time I’m seeing a male counselor. I don’t really worry about that too much, but I’m not exactly used to that and don’t really know what to expect of it either. I’m rambling…I don’t really know.