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Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration

Martin J. La Roche1 and Jill Betz Bloom2

Abstract

After years of extensive research, the Cultural Formulation Interview (CFI) was released in the fifth edition of the

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Similar to its predecessor, the Outline of the Cultural

Formulation (OCF), the CFI aims to refine the psychiatric assessment process by systematically examining cultural factors.

However, in contrast to the OCF which employs open-ended questions, the CFI uses a semi-structured interview format.

Unfortunately, children and adolescents have only been included in a handful of OCF and CFI studies, which raises questions

about their applicability with youth, particularly young children (11 years or younger). In this article, we start examining the

usefulness of the CFI with young children and propose recommendations to enhance its benefits by suggesting the devel-

opment of a supplementary module specifically designed for young children. These ideas are illustrated with the assessment

of a 6-year-old boy of Somali descent.

Keywords

assessment, children, cultural diversity, Cultural Formulation Interview, refugees, Somali

The Cultural Formulation Interview (CFI) was first introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association (APA), 2013). The CFI is a more standardized version of the Outline of the Cultural Formulation (OCF), which was first described in the DSM-IV (APA, 1994). The CFI oper- ationalizes many of the OCF’s questions into a semi- structured interview composed of 16 questions with explicit instructions to assess an individual’s experience and social context. While the OCF was relegated to the ninth appendix of the DSM-IV (APA, 1994), the CFI is described in the more prominent section III of the DSM- 5 (APA, 2013), which seems to reflect its increased cred- ibility (La Roche, Fuentes, & Hinton, 2015).

The CFI was designed to identify cultural and con- textual factors relevant to the diagnosis and treatment of different problems; it aims to more accurately under- stand patients’ symptoms and world views by examin- ing them in relationship to their cultural context. The underlying assumption of the CFI is that culture shapes a patient’s perspective and approach to clinical care, influencing when, where, how and to whom patients narrate their experiences of illness and distress

(Kirmayer, 2006). In addition, the authors of the CFI (Lewis-Fernández, Aggarwal, Hinton, Hinton, & Kirmayer, 2016) underscore culture’s fluidity and con- ceptualize it as an open dynamic system that undergoes continuous change over time. Furthermore, the CFI authors explain that most individuals and groups are exposed to multiple cultures and socioeconomic con- texts (Lewis-Fernández et al., 2016).

In contrast to the DSM-5’s prevalent biomedical view of disorders as constellation of symptoms that are accurately examined independently of their cultural context, in the CFI mental health disorders are concep- tualized as embedded in cultural contexts (La Roche et al., 2015; Regier, Narrow, Kuhl, & Kupfer, 2011). The CFI explores symptoms as locally shaped by dif- ferent cultural contexts.

Transcultural Psychiatry

2020, Vol. 57(4) 515–524

! The Author(s) 2018

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DOI: 10.1177/1363461518780605

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1Boston Children’s Hospital and Harvard Medical School 2William James College

Corresponding author:

Martin J. La Roche, Boston Children’s Hospital/Harvard Medical School,

75 Bickford St, Jamaica Plain, MA 02130, USA.

Email: [email protected]

Directly assessing patients’ cultural characteristics and contextualizing their symptoms allows clinicians to design psychotherapeutic treatments based on these characteristics rather than cultural stereotypes (Lewis- Fernández et al., 2016). Furthermore, directly assessing patients’ cultural beliefs, idioms of distress or meanings helps practitioners avoid misdiagnosis, obtain clinically useful information, improve clinical rapport and thera- peutic efficacy, guide research and training, and clarify cultural epidemiology (Lewis-Fernández et al., 2016). In fact, there is a growing literature that demonstrates that complementing psychiatric assessments with the OCF or CFI significantly increases the accuracy and cultural validity of DSM’s diagnoses (Bäärnhielm, S., Åberg Wistedt, & Scarpinati Rosso, 2015; Kirmayer, Thomb, Jurcik, Jarvis, & Guzder, 2008; Lewis- Fernández et al., 2016). Nevertheless, employing the CFI by itself does not result in a diagnosis. The infor- mation obtained by the CFI must be integrated with other clinical material to produce a comprehensive clin- ical and contextual evaluation. In addition, it is import- ant to clarify that the CFI guidelines do not require clinicians to have a thorough knowledge of their patients’ cultural background. However, an enhanced knowledge of patients’ cultural background often increases CFI’s diagnostic accuracy (Lewis-Fernández et al., 2016).

The CFI is described as ‘‘a work in progress’’ or a ‘‘living document that will be modified with new know- ledge’’ (Kirmayer, 2016, p. 268). The CFI (see Appendix 1 in the Supplemental Online Material) explores the following four areas: 1) Cultural definition of the problem; 2) Cultural perceptions or understand- ing of the cause(s) of the problem, which includes two subareas, stressors/supports and role of cultural iden- tity; 3) Cultural factors affecting self-coping and past help-seeking; and 4) Cultural factors affecting current help seeking. Two versions of the CFI are available, one for patients (which will simply be referred to as CFI) and a CFI-Informant Version. The CFI is directly administered to patients and gleans information from their own world view, while the CFI-Informant Version is completed by significant other(s) of patients or people who can provide relevant information about them or their context. The CFI-Informant Version aims to assist clinicians in conducting a cultural assess- ment of the presenting clinical problem from the per- spective of key informant(s) such as spouse, other family member(s), teacher(s) or other significant per- son(s) in their life who can offer clinically relevant information. When collateral information is possible, the CFI-Informant Version supplements what patients report or it may become the primary source of infor- mation when patients are unable to participate actively in their assessment, such as in the case of young

children, individuals with cognitive impairment or florid psychosis (Lewis-Fernández et al., 2016). Often, only the CFI-Informant Version is used with the par- ents and/or teachers of a child, while neither CFI ver- sion is directly used with children, particularly young children (Rousseau & Guzder, 2016). Both CFI ver- sions measure the same four areas but the CFI- Informant Version does so from the perspective of per- son(s) close to the patient and it includes the following question: ‘‘How would you describe your relationship to the patient?’’

Both CFI versions can be complemented by one or several of the 12 Supplementary Modules (e.g., cultural identity). Each of these 12 modules provides additional and more detailed questions to assess specific domains briefly explored in the CFI as well as questions that can be used during the cultural assessment of particular groups, such as children and adolescents, older adults, and caregivers. Evaluators can decide to use several or none of these 12 supplementary modules.

Over 150 published studies have employed the OCF. Given the CFI’s semi-structured format, it is likely that a greater number of research studies will soon start benefiting from its easier use (Lewis-Fernández et al., 2016). However, the vast majority of OCF studies have used adult samples. Only a handful of publications were identified that have used the OCF with children, particularly young children. In this paper, the term ‘‘young children’’ refers to youth who are 11 years of age or less, or youth who have not reached the formal operations stage. According to Piaget (1972) the formal operations stage is the last cognitive stage in an indi- vidual’s development and it entails an ability to think in abstract terms and think critically and comparatively about situations. The age at which the formal operation stage emerges varies from culture to culture but in industrialized and highly-educated countries it often starts developing around the time the child is 11 years of age (Cole, 1998).

The handful of researchers (i.e., Novins et al., 1997; Mian, Al-Mateen, & Cerda, 2010) who have employed the OCF with children have consistently noted its potential to assess cultural issues and suggested that the paucity of OCF research is explained by the fact that it was designed for adults. As a means to address OCF’s significant limitations in assessing children, the CFI incorporated two main additions (Rousseau & Guzder, 2016). First, it included the CFI-Informant Version that is administered to people who are signifi- cant in a child’s life, such as parent/guardian(s) and teachers, and second, it crafted a supplementary module 9 entitled ‘‘School-Age Children and Adolescents’’ (SACA) to be directly administered to the child (see Appendix 2 in the Supplemental Online Material).

516 Transcultural Psychiatry 57(4)

The first improvement underscores the importance of using the CFI-Informant Version with children’s parent(s) or guardian(s), which acknowledges that they are key to their children’s clinical presentation. In addition, the possibility of having several people complete supplemental forms reflects the complexity of cultural views and contexts. The child is exposed to multiple cultural influences at home, school, and in their communities. Even within the same family each parent or sibling may have distinct cultural views (e.g., different acculturation levels) that can be assessed through different informant versions.

The development of a supplementary module for SACA is a second significant improvement included in the CFI to assess children. The SACA module is designed to help clinicians explore age-related cultural dimensions. The questions are purposefully indirect to allow children or adolescents to express their feelings of being special or different or from a specific culture. The questions are written to yield the child’s representations of normality at home or challenges growing up at school, with friends or their community, which acknowledges that a child’s normal development is defined in cultural terms. The module includes 20 ques- tions in four main areas.

However, even this module specifically designed for children and adolescents contains the following caveats, ‘‘this supplement is directed to adolescents and mature school-age children. . . Some children may not be able to answer all questions; clinicians should select and adapt questions to ensure they are developmentally appropriate for the individual’’ (Lewis-Fernández et al., 2016, p. 309), which raises questions about its utility with young children. It is likely that the devel- opers of this module were concerned that its questions required formal operations thinking and that it relied too heavily on language. For example, question 14 (i.e., What do other children/youth your age expect from child/youth your age?) may not glean very different information from question 13 (e.g., What do your par- ents or grandparents expect from you?). The difference between questions entails contrasting contexts, which is a formal operation skill.

Kirmayer (2016) explains that the CFI has much potential as an assessment tool, yet it is still unclear how it is used in the clinical process. This is particularly important as assessment and treatment processes are not independent from each other. Furthermore, Kirmayer (2016) argues that the CFI stopped short of creating a more structured template that could link and organize the assessment data to clinical issues. In the assessment of young children, we outline several ideas to connect the information yielded by the CFI to the psychiatric assessment, which could be very useful for mental health providers working with young children

who need to glean and organize information from mul- tiple sources (e.g., school, family). Having an outline to organize this information may not only clarify the information but also save time. Not considering cul- tural information can lead to significant assessment and clinical errors (Kirmayer, 2016). As a result, clin- icians and researchers may start viewing the CFI as an invaluable tool to organize information in a more cul- turally valid manner instead of viewing it as another cumbersome scale to administer. However, to outline this process we need to start by briefly describing the psychiatric assessment and its main components.

The psychiatric assessment is the process of gather- ing information by a mental health provider (e.g., psychiatrist, social worker) about a patient within a psychiatric or mental health service with the purpose of making an accurate diagnosis (Angold et al., 1995; Maxmen & Ward, 1994). The psychiatric assessment is the first stage of any mental health treatment. Many outlines to conduct psychiatric assessments have been developed. Nevertheless, most include the following six components (Maxmen & Ward, 1994): 1) ‘‘Chief Complaint(s)’’ in which the main reason(s) patients are seeking mental health services are described; 2) ‘‘History of Problems’’ or how patients’ problems have evolved through time; 3) ‘‘Mental Status’’ or the symptoms patients are presenting; 4) ‘‘Diagnosis’’ which is a category(s) that reflects the constellation of symptoms patients are presenting; 5) ‘‘Biopsychosocial Formulation’’ or an explanation of why patients are experiencing certain symptoms and; 6) ‘‘Treatment Plan’’ or a systematic set of strategies designed to ameliorate patients’ symptoms. Additional components have also been used in the psychiatric assessment (Maxmen & Ward, 1994) (e.g., prognosis, physical examination), which are not herein included because they are not significantly influenced by the information yielded through the CFI. The way in which each of these six psychiatric assessment components is informed by the four areas of the CFI are outlined and illustrated through a psychiatric assessment of a 6-year-old boy of Somali descent conducted by the first author of this article, who is a Latino, male psych- ologist in his mid-50s. The goal of this paper is to start examining the utility of the CFI with young children and to suggest strategies to refine its use with young children. To ensure confidentiality identifiable data has been disguised or modified.

Case example

Jamaal came to the clinic located in their neighbour- hood with his mother and interpreter. The clinic is the oldest standing community health center in the United States and has a long tradition of serving and

La Roche and Bloom 517

welcoming diverse communities. The same interpreter was present for both assessment sessions. Before the session, all releases, consents, and confidentiality agree- ments were explained and signed. Jamaal was a well- groomed boy, with a shy smile and bright eyes, and appropriately dressed for the fall weather. He was born in Boston six years ago to Somalian parents. Jamaal speaks English fluently but his parents have a very limited understanding of English and are unable to express themselves in English. His parents recently separated for unspecified reasons. Although his father now lives in a different town he still visits Jamaal and his four siblings every day. Jamaal is the youngest; his two brothers are 22 and 17 years of age and his sisters are 15 and 8. Jamaal reported having a good relation- ship with his parents and each of his siblings.

His parents arrived in Boston 25 years ago fleeing escalating violence in Somalia. Civil war broke out in Somalia in 1988 leading to a massive population dis- placement that continues to this date. Currently, the Somali and Somali Bantu populations are the largest African groups living in the United States (Johnson, Ali, & Shipp, 2009) and constitute 45% of the African refugee population (Carroll et al., 2007). As a result of the civil war and the immigration journey to the US, many families have experienced severe violence. These traumatic experiences are often compounded in the US by resettlement stressors, acculturative stres- sors, poverty, and discrimination (Betancourt, Abdi, Ito, Lilienthal, & Agalab, 2015). Research indicates that among relocated Somalis, mental health diagnoses such as depression, post-traumatic stress disorder (PTSD), and anxiety range from 14% to 31.5% of the population (Boynton, Bentley, Jackson, & Gibbs, 2010) with 50% prevalence rate in some studies (Guerin, Guerin, Diiriye, & Yates, 2004).

Despite Somalis’ extensive need for mental health ser- vices, they rarely seek help. Furthermore, children utilize services even less often than adults (Ellis et al., 2010). Multiple barriers (e.g., language differences, difficulty accessing health services) often deter Somalis from seek- ing mental health services. However, researchers (e.g., Bettmann, Penney, Clarkson-Freeman, & Lecy, 2015; Ellis et al., 2010) explain that underutilization is also a result of Somalian cultural beliefs that often clash with Western mental health assumptions. For example, many Somalis believe that having PTSD or depression is a sign of weakness that is best dealt with by staying at home. Rather than seeking outside services families encourage their ill family members to stay home as a means to protect them from being publicly humiliated or insulted (Bettmann et al., 2015).

I first met with Jamaal’s mother, Mrs. S. while Jamaal played quietly in the waiting area. Mrs. S was a tall, slim woman in her late-30 s wearing a colorful

and highly ornamented hijab or veil. In an effort to establish rapport with her I inquired about transporta- tion issues. Once I felt that rapport had been estab- lished I asked ‘‘what brings you here?’’ which is the first question of the CFI informant version. This is also the first question of many psychiatric assessments and addresses patients’ chief complaint. She said ‘‘my son’s pediatrician Dr. O. recommended that Jamaal receive counseling.’’ Following CFI’s outline, I added. ‘‘People sometimes understand their problems in their own way, which may be different from the way in which doctors describe the problem.’’ Jamaal’s mother pro- ceeded to explain that her eldest son Mohamad, 22 years of age, was shot in front of their home and that he is still recovering from numerous gun wounds. The ‘‘criminal was never caught by the police.’’ According to traditional Somali culture, an assault to a family member is an affront to the entire family, which reflects the close-knit kinship relationships emphasized in Somalia (Wolf et al., 2014). Frequently after an assault mental health assistance is not sought; instead the assailant is required to pay damages to the family (Scuglik, Alarcón, Lapeyre, Williams, & Logan, 2007). Overall, this information about Somalian culture was used as hypotheses that could clarify Jamaal and his family’s experience. Nevertheless, these hypotheses had to be confirmed by their narratives (Kleinman, 1988; La Roche, 2013), which seemed to be the case as Jamaal’s mother said, ‘‘I don’t think the police care about Africans because they never caught the criminal.’’ The mother’s focus was on capturing the shooter so that he would have to compensate the family for the assault. She added that ‘‘they [police] don’t care about us or they would have caught the criminal. . . shootings are very frequent where we live. Our next-door neighbor was also shot a few months ago. We live in a very dangerous neighborhood. . .’’

Mrs. S. explained that the frequent neighborhood shootings were making Jamaal very nervous; he was having nightmares and he was not eating at school. Even his pediatrician was worried because he had lost weight. Mrs. S. continued, ‘‘after Mohamad [eldest son] was shot, Jamaal has not been the same. Before the shooting Jamaal was a happy child but now, he doesn’t go outside by himself. He doesn’t eat breakfast at school and he doesn’t play with his friends.’’ I asked how he played with his friends before and after the shooting. His mother responded, ‘‘before he never seemed afraid of going out but now he seems afraid of walking alone on the street.’’ She identified his night- mares, poor appetite and fear of walking alone as the most troubling aspects of his behavior, which were a response to question 3 of the CFI, which is also a good question to start exploring patients’ mental status. I asked many additional questions examining his mental

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status. As his symptoms were identified a history of problems was also completed. It was found that before his brother was shot he did not present anymajor mental health symptoms (e.g., nightmares, lack of appetite).

In exploring the cultural perceptions (CFI’s questions 4–7) of the causes of Jamaal’s problems his mother explained that the shootings were the main reason for his problems. She indicated that Jamaal’s father and extended family also believed this was the case. One of the advantages of the information gleaned through the CFI questions is that it can add cultural specificity, not typically obtained, using standard psychiatric assess- ments. For example, as I continued to explore what vio- lence and Jamaal’s symptoms meant for them, Mrs. S. angrily said,

Americans do not care about Africans or Muslims.

Whites have dumped us in a bloody neighborhood so

that we kill each other. This is what Donald Trump

wants, isn’t he saying that he wants to get rid of all

Muslims?

Having experienced much discrimination from white people, Jamaal’s family found it difficult to trust them. I understood this could become a significant treatment barrier and that it should be addressed as soon as possible. Nevertheless, she quickly moved on to talk about housing issues.

Mrs. S. then described her repeated efforts to move out of the neighborhood and her frustration in com- pleting subsidized housing applications. Her English was not good enough to complete these forms, which would allowed me to further explore her self-coping and past help-seeking behavior when facing significant challenges (CFI question 11–13). Jamaal’s mother iden- tified that two crucial barriers for the well-being of her family were poverty and living in a violent neighbor- hood. She said that ‘‘it is very frustrating to seek help. When I phone people, they hang up on me. They do not understand my English but I keep trying for my family.’’ I offered to refer her to a case manager, to which she responded that in the past case managers had been useless. She explained that her previous case manager was ‘‘a very busy woman who did not seem to have time for my family. She did not answer my ques- tions just like most Whites don’t. Whites don’t care for Muslims. . .’’

In inquiring about her preferred types of help (CFI questions 13–15) I asked her what I should do to ensure that I did not make the same mistakes since I am not Muslim nor African. She answered that, ‘‘I should really try to care.’’ I asked her to explain what she meant by caring as it means different things for differ- ent people. Smiling, she said that we would have to work together to find that out. I asked further what a

good relationship would look like and she said that she would surely tell me if I was not caring enough.

Some of the CFI identity questions (questions 8–10) were not addressed in order or even during the same assessment session but much information was provided about their identity from the onset and throughout the assessment. For example, I realized that Mrs. S. used the plural form of words frequently, using the word ‘‘we’’ to refer to herself, Jamaal, or the family. Although, most people would agree that it is impossible to work with a child without the family, I soon realized that her identity and family were intricately interwoven. Her identity was more a reflection of family relation- ships than an individualistic, isolated construal of the self. Reflecting this view, in the treatment plan I under- scored the importance of including the family in the psychotherapeutic process. Moreover, her identity as a Muslim and African was central and often construed in opposition to American traditions and assumptions. She believed that because of her family’s religion, skin color, and place of birth they were discriminated against and marginalized in Boston.

Consistent with CFI guidelines (question 16) I fur- ther explored the meaning of cultural differences. I encouraged her to discuss any concerns that she might have had because I am Latino and not Muslim. Nevertheless, it is important to note that many add- itional cultural differences are also present, such as gender and educational level, that needed to be dis- cussed (La Roche, 2013). However, many patients choose not to address cultural differences during the first few sessions. Most patients have many and more pressing issues to discuss. Nevertheless, by asking the CFI questions the message was conveyed that it was appropriate to discuss cultural differences within the psychotherapeutic session. Some patients choose to take advantage of this possibility in later sessions (La Roche, 2013).

After Jamaal came to the office I asked a few rap- port-building questions before I asked the first question of the CFI to which he did not seem to know how to respond. Even after I clarified the question he just looked to the floor. I then proceeded to administer the SACA supplementary module (see Appendix 2 in the Supplemental Online Material) and I asked, ‘‘I would now like to know more about your feelings about being 6 years of age?’’ He limited himself to say, ‘‘it’s ok.’’ I then asked ‘‘do you feel like other chil- dren/youth your age?’’ to which he did not seem to know how to respond. The interviewer has repeatedly experienced the same situation where young children of different ethnic backgrounds do not know how to respond to any of the CFI’s questions including the SACA module. More often than not the answer is ‘‘I don’t know’’ or ‘‘my mother brought me here.’’

La Roche and Bloom 519

I asked Jamaal if he would like to draw or build something and he took some paper and crayons and started drawing four thick walls that looked like a ‘‘fort’’ and he drew himself inside. He stated that ‘‘he was in his home playing ball.’’ I asked how it is to be home and he responded, ‘‘it’s good inside the house, but outside it’s bad.’’ He did not respond when I asked him to draw the outside. I then asked him what is good about being inside and bad outside and he said,

Inside I have my family and we are happy together, but

outside there are many shootings. . . One time my

brother was shot. Many policemen and ambulances

came. There were lots of people. . . Another time I

was looking outside the window and there was another

shooting. I am very scared. I am scared that I will get

shot. I am scared that my mom will get shot. . . I am

scared of going outside so I stay inside. I play with my

tablet, watch TV and play with my sisters.

Following the SACA module questions I inquired about stressors and supports. His family was identified as a source of support while his neighborhood was viewed as a dangerous and stressful place.

In addition, he reported having frequent nightmares in which he was shot by streets thugs or kidnapped, ‘‘they are very scary’’ he explained. Furthermore, Jamaal reported often feeling dizzy and that his heart beat very quickly. Jamaal also had difficulty breathing and even feeling some ‘‘belly ache.’’ This was particu- larly true if he heard a loud or unexpected noise. Jamaal added, ‘‘my eyes get fuzzy and my head hurts. . . every time I am dizzy something bad happens.’’

As I continued to explore stressors and supports I learned that Jamaal and his family were very supportive with each other and their Somalian next-door neigh- bors. When I asked Jamaal what made him feel happy he did not say anything but immediately started drawing his family. He drew 12 family members all very close to each other and he indicated that they were smiling because they were ‘‘happy together.’’ Five of these 12 were his neighbors. In addition, Jamaal drew himself very close to his mother and spontaneously reported loving his mother and in turn, his mother smiled at him and said, ‘‘I love you, too.’’

In many groups such as in the Somali culture, ‘‘family’’ is defined differently than in the typical Western nuclear family; it may not only include blood relatives but also close friends (Wolf et al., 2014). This understanding may have implications when utilizing different play therapy tools such as doll houses that encourage children to reflect family dynamics in their own language. Instead of using one doll house as sug- gested by most play therapy texts I have used several doll houses to more thoroughly capture their

experiences. This approach was particularly useful with Jamaal because when I asked him about his family he immediately started playing with my doll- houses. Suddenly, Jamaal loudly said ‘‘bang’’ and all the human figures ran from the first dollhouse to the second. He again yelled ‘‘bang’’ and now all the figures ran from the second house to the first. His mother explained that her family would often run to their neighbor’s home if they heard a shooting closer to their home than that of their friends. Similarly, their neighbors would hide in Jamaal’s home if the shooting seemed closer to the neighbors’ home. Jamaal added that he felt safer and stronger together. Mrs. S. con- cluded that ‘‘family is good.’’

Jamaal also reported feeling safe as he heard the words of the Qur’an and he reported enjoying asking questions about it. Many of his siblings would also join in during these readings that seemed soothing not only for Jamaal but for the entire family. In much of the Somalian mental health literature (Bettmann et al., 2015; Tiilikainen & Koehn, 2011) religious beliefs and practices are underscored as a source of support. Consistent with his self-report and Somalian mental health literature I encouraged Jamaal to recite prayers whenever he felt that his heart was pounding quickly or that he could not breathe. He realized that as he heard the words of the Qur’an he felt more relaxed. He and his mother explained, ‘‘Allah is great and He is giving us strength.’’ This belief could have motivated him to pray which in turn may have heightened his sense of mastery over his anxiety symptoms. It was clearly noted in the treatment plan that Jamaal would benefit from relaxation strategies that incorporated prayers rather than more traditional guided imagery. If the CFI had not been used, standard relaxation strategies that are not consistent with Jamaal’s cultural frame may have been used, which could have reduced treatment adher- ence and outcome (La Roche, 2013). Similarly, empha- sizing treatment with Jamaal’s family (e.g., praying together) rather than working with him alone was a result of Jamaal’s relational/family world view.

When I asked Jamaal to draw himself at school he did so alone in a class and did not say much more. Mrs. S. indicated not knowing how he was doing at school. She explained that Jamaal’s previous teacher had been in frequent contact with her. However, his current tea- cher was not as good and added ‘‘I have not talked with her.’’ She explained that parents are not supposed to bother teachers with questions, which is why she had not reached out to her. Nevertheless, she said that it is okay for me to call his teacher. Per her request, I phoned the teacher. I was hoping to administer the CFI-Informant Version but the teacher’s fast and abrupt response style only permitted me to ask a hand- ful of questions. The teacher started by saying ‘‘I have

520 Transcultural Psychiatry 57(4)

only known him for the month of September so I don’t know him well, but he seems like a shy and easy-going boy that talks okay with his peers.’’ She quickly added ‘‘I have no worries about him, he is a charming and sweet child.’’ After a few more comments she reported having to go back to class.

In an effort to outline treatment goals I said, ‘‘it seems that much of our work will be in finding ways for Jamaal to start eating, feel less nervous, have fewer nightmares and start having friends.’’ Immediately, Jamaal and his mother nodded. One of the first findings within the cultural psychotherapeutic literature is that having agreed upon psychotherapeutic goals increases the likelihood that patients remain in treatment (Sue, 1977). Numerous authors underscore the need to clarify treatment goals in a culturally sensitive manner, which means in terms that are clearly understood by patients and clinicians. To accomplish this goal, it is often bene- ficial to clarify and use patients’ terminology (e.g., diz- ziness, headaches). Understanding and using patients’ language has repeatedly been found to promote empa- thy and improve the psychotherapeutic relationship. Furthermore, their concerns led us to formulate two additional sets of treatment goals. First, to assist the family to move out of their neighborhood for which I wrote a letter of support. Second, to help them receive food stamps for which I assisted them in their welfare application. However, I also clarified expectations. I validated their concerns that I may not be able to help them move out of their neighborhood as quickly as they wished. Nevertheless, I also assured them that I would do everything in my power to help them. In add- ition, I made it clear that in the meantime we would focus on helping Jamaal. I asked them if this is what they needed from me and they agreed. I also reminded them that we could add and revise these treatment goals at any time.

Psychiatric assessments require a DSM-5 diagnosis which is clarified with information from the CFI. Jamaal met all eight PTSD criteria as described on the DSM-5 (APA, 2013). Consistent with PTSD’s cri- terion A, Jamaal was directly exposed to significant life threating events (e.g., his brother was shot and he had witnessed frequent shootings). Criterion B is that he presents with recurring involuntary memories asso- ciated with trauma (e.g., nightmares). Jamaal is also meeting criterion C as he is also persistently avoiding stimuli associated with the traumatic event (e.g., not going outside). Criterion D is experiencing negative alterations of mood or cognitions related with trau- matic event(s), which Jamaal also meets. For example, he is frequently very anxious and fearful that criminals will attack his home. Similarly, criterion E is met, which is experiencing significant alterations in arousal and hyperactivity (e.g., tachycardia, breathing problems).

Symptoms have lasted for over one month meeting cri- terion F. Similarly, criterion G is also met as he has started to present significant social impairments at school. Finally, criterion H is also met as the disturb- ance is not attributable to physiological effects of a substance or a medical condition.

Jamaal may have met criteria for PTSD according to the DSM-5 (APA, 2013); nevertheless, he and his family have understood his issues very differently. In contrast to the DSM-5 that underscores symptoms residing within patients, they viewed Jamaal’s issues as inseparable from the social context. Jamaal’s prob- lems were a result of countless and ongoing unjust socioeconomic and political conditions that have harmed them even before his birth. These injustices range from distant events such as the outbreak of the civil war in Somalia to the everyday violence experi- enced in their neighborhood in the US, to more current events such as President Trump’s anti-Muslim rhetoric during the 2016 presidential race. Furthermore, these issues do not only reside within Jamaal but within the family and social context. Therefore, treatment should focus on helping his family and not only on ameliorat- ing Jamaal’s symptoms but also on improving or ‘‘treating’’ the social context (e.g., helping them move). Finally, Jamaal’s family viewed his problems not as symptoms; rather as reactions to abnormal and unjust situations. (Bloom, 2016). Jamaal’s clinician will benefit if he uses a vocabulary that is consistent with the family’s cultural understanding as a means to avoid pathologizing and stigmatizing them (Kleinman, 1988; Lewis-Fernández et al., 2016). If this language is not used it is likely that the family will drop out of treat- ment (La Roche, 2013). One of the main advantages of the CFI is that it encourages patients’ narratives to be viewed from their own perspective. Furthermore, the information yielded by the CFI is not final but an ongoing approximation to their current point of view, which underscores the need to continuously assess patients’ cultural views (Lewis-Fernández et al., 2016).

Conclusion

As illustrated in Jamaal’s case the CFI is a powerful tool to accurately assess in a culturally sensitive manner young children’s symptoms. The questions of the CFI can address issues that may have been omitted or not explored sufficiently by standard psychiatric assess- ments. For example, issues of mistrust towards white people are rarely examined in psychiatric assessments, but thanks to the CFI these were directly assessed in Jamaal’s assessment. If these cultural differences had not been discussed, it is likely that past therapeutic rup- tures (e.g., not caring enough) would have been repli- cated during the assessment process. Similarly, the CFI

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questions allowed the design of a more thorough treat- ment plan that included prayers and family supports. The inclusion of cultural characteristics within the treatment plan often enhances treatment adherence and outcome (La Roche, 2013; Lewis-Fernández et al., 2016).

Even though Jamaal’s views (e.g., through drawing and play) were a significant contribution in developing a cultural understanding of his issues, the standard questions of the CFI were not very helpful in reaching this understanding. Jamaal did not respond to most of the traditional questions of the CFI including the SACA module. Much of the information gleaned through the standard administration of the CFI was provided by Jamaal’s mother and his playing and draw- ing. The CFI relies much on language and more advanced developmental (e.g., formal operations think- ing) questions that often do not take sufficient advan- tage of young children’s views. Children often express themselves more concretely through drawings or play. Given these limitations and in agreement with the spirit of the CFI, which is eloquently described (Kirmayer, 2016) as a living document with much flexibility and potential for growth, the development of a supplemen- tary module for young children is herein suggested.

The development of an additional supplementary module for young children is based on the idea that formal operations and advanced language skills are not necessary to tap into children’s’ cultural views. Concrete questions and play can reveal much of chil- dren’s cultural perspectives. For example, instead of relying solely on words, children can be encouraged to draw, build/sculpt (e.g., cutting cardboard/paper using or play dough), act (through puppets or role play dramatizations) or any other means that they choose to represent their views of themselves and their significant contexts/worlds, including: 1) home/ family, 2) school 3) their neighborhood, and 4) self. Children can first be asked to describe each context (e.g., school, home) independently of others. More detailed questions can follow up on specific issues of each category (e.g., what is happening and what will happen in the street?) as well as the SACA module questions. Clearly, these are preliminary ideas and more research is needed to develop a supplementary module with young children.

Our proposed supplementary module for young chil- dren would necessarily rely on a play therapy tool box that includes puppets, dollhouses, play dough, etc. Nevertheless, a cautionary note when using play ther- apy tools is that these are often culturally biased (e.g., skin color of the puppets or use of only one dollhouse). It is thus necessary for clinicians and researchers to examine the cultural applicability of each of these tools with their patients before they are used.

In addition, some ideas to start linking the CFI with the psychiatric assessment with young children have been outlined throughout the clinical illustration. It is hoped that by linking the four CFI areas to the psychi- atric assessment clinicians and researchers working with young children and who often need to obtain add- itional information from several sources (e.g., school) in comparison with clinicians working with adults, will not only be able to more effectively organize their infor- mation but also obtain more in-depth and useful clin- ical information. The first two CFI questions about the cultural definition of the problem, for example, can be used to understand patients’ chief complaint or the reasons for which they seek treatment. Question 3 is a good start to explore patients’ mental status. It is neces- sary to ask in a culturally sensitive manner additional questions to obtain a complete mental status. The cul- tural perceptions of the causes of the problems (ques- tions 4–10) can inform the development of a shared understanding of what caused the problems or formu- lation, after which treatment goals can be defined and prioritized. Exploring past help-seeking and self-coping (questions 11–13) as well as the questions of current help-seeking (questions 14–16) can allow patients and clinicians to design more culturally competent healing strategies (e.g., including prayers) and/or refine existing ones.

One single case illustration is insufficient to offer a thorough examination of the CFI with young children. Nevertheless, it is hoped that Jamaal’s case highlights the need to listen to young children’s voices and cul- tural interpretations. Unfortunately, their voices have often been neglected from the cultural literature. This lack underscores the need to continue researching and refining the utility of powerful cultural tools such as the CFI with young children.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this

article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Martin J. La Roche, PhD, has been Director of Training at the Martha Eliot Health Center at Boston Children’s Hospital, which is the oldest standing com- munity health center in the country, for the last 22 years. He is an Associate Professor in Psychology at the Harvard Medical School/Boston Children’s Hospital and specializes in the development of cultur- ally competent psychotherapeutic and assessment stra- tegies. Dr. La Roche has over 100 peer reviewed publications/presentations on cultural competent treat- ments with ethnic minorities and has been Principal or Co-Principal Investigator on many research projects. Dr. La Roche is also the author of a book entitled Cultural Psychotherapy: Theory, Methods, and Practice. In addition, he has received many research/ academic awards such as the Harvard Bridge Award, The Milton Award, and was Selected Outstanding

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Committee Chairperson of the Year by the Massachusetts Psychological Association.

Jill Betz Bloom, PhD, is an Associate Professor in the Department of Clinical Psychology at William James College in Boston, where she is Co-Director of the Center for Multicultural and Global Mental Health, and Director of the Global Mental Health Program.

Dr. Bloom’s current work in global mental health includes co-leading service learning immersion pro- grams in Haiti and Guyana, with a focus on community capacity building. Her research and publications focus on sex trafficking, global gender violence and trans- national feminism, and a book project on the social and cultural history of psychiatric diagnosis.

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