Update on the Cultural Formulation Interview

May combine two claims.

The CFI has been evaluated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally found clinically acceptable and useful in these varied settings.

“The CFI has been evaluated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally has been found to be clinically acceptable and useful in these varied settings.”

• cites [10] sourcePartly supported

  The study-design passage lists sites in Canada, India, Kenya, the Netherlands, Peru and the USA, but not Mexico. The Main findings report that patients and clinicians generally found the CFI acceptable and clinically useful across the trial sites. Thus the assessment is supported for six of the seven countries named, not Mexico. (LLM, conf=0.90)

  Experimental — accuracy not yet measured
• cites [12] Baarnhielm S, 2016Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [13] sourcePartly supported

  The Introduction (page not available) says CFI field studies were conducted in the U.S., India, Peru, the Netherlands, Canada and Kenya, but does not list Mexico. The Results report that participants in Pune rated the CFI acceptable and useful; the Discussion says cross-site analysis was still forthcoming, so this paper does not establish that finding across the listed settings. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

The OCF received limited application by psychiatrists and mental health practitioners, perhaps in part because it did not guide clinicians in how to elicit cross-cultural information, especially clinicians who were not already experienced in cultural assessment.

“However, the OCF received limited application by psychiatrists and mental health practitioners, perhaps in part because it did not guide clinicians in how to elicit cross-cultural information (3,4), especially clinicians who were not already experienced in cultural assessment (5).”

• cites [3] sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured
• cites [4] sourceNot checked — no full text of the source
• cites [5] sourceNot checked — no full text of the source

May combine two claims.

The CFI was acceptable to family members accompanying patients, but patients and clinicians rated the CFI lower when relatives were present.

“The authors found that the CFI was acceptable to family members accompanying patients but that patients and clinicians rated the CFI lower when relatives were present.”

• cites [13] sourceSupported

May combine two claims.

Relatives tended to raise additional aspects of the presenting problem, which tended to make the clinical assessment more complicated.

“In addition, relatives tended to raise additional aspects of the presenting problem, which tended to make the clinical assessment more complicated.”

• cites [13] sourceSupported

May combine two claims.

The CFI is feasible, acceptable, and useful in international field trials.

“Mixed-methods evaluation found the CFI to be feasible, acceptable, and useful.”

• cites [10] sourceSupported

Classified as probably not a substantial claim.

Respondents felt that mock interviews helped them to learn how to ask the CFI questions and resolve their doubts about the interview.

“Respondents felt that mock interviews helped them to learn how to ask the CFI questions and resolve their doubts about the interview.”

• cites [26] sourceSupported

May combine two claims.

For patients, the most common concerns about CFI implementation were lack of differentiation from other interviews, discomfort with discussing the past or talking about religion, and difficulty understanding some CFI questions.

“For patients, the most common concerns were lack of differentiation from other interviews they had received, discomfort with discussing the past or talking about religion, and difficulty understanding some CFI questions.”

• cites [17] sourceSupported

May combine two claims.

The New York State Center of Excellence for Cultural Competence developed an online training module on how to use the CFI and reported its use by 423 service providers in the state, mostly social workers and other nonmedical counselors.

“The New York State Center of Excellence for Cultural Competence developed an online training module (https://nyculturalcompetence.org/cfionlinemodule/ ) on how to use the CFI and reported its use by 423 service providers in the state, mostly social workers and other nonmedical counselors (27).”

• cites [27] sourcePartly supported

  The Description of the Module says the Center of Excellence for Cultural Competence developed the CFI module with the Center for Practice Innovations. Participant Characteristics reports that 423 providers completed it, mostly social workers and other providers including counselors. The paper does not establish that all 423 providers were in New York State; the module was also available beyond the state. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

CFI training might best be accomplished through a combination of written guideline review, video demonstration, and behavioral simulations.

“The authors concluded that CFI training might best be accomplished through a combination of written guideline review, video demonstration, and behavioral simulations but that older, more experienced clinicians tended to prefer active rather than passive learning techniques.”

• cites [26] sourceSupported

May combine two claims.

Of the 321 patient interviews in the DSM-5 field trial, 86 at four of the 12 sites included family members, who generally found the CFI acceptable, although some found the questions too time consuming, intrusive, or personal.

“Investigators found that of the 321 patient interviews in the DSM-5 field trial, 86 at four of the 12 sites included family members, who generally found the CFI acceptable, although some found the questions too time consuming, intrusive, or personal (25).”

• cites [25] sourceSupported

May combine two claims.

For clinicians, the most common concerns about CFI implementation included lack of clarity about the relevance of the CFI to the presenting problem, diagnostic assessment, and intervention planning; doubts about using the full CFI at the beginning of an evaluation; repetitiveness; difficulty engaging patients with severe illness; and lack of clinician buy-in.

“For clinicians, the most common concerns included lack of clarity about the relevance of the CFI to the presenting problem, diagnostic assessment, and intervention planning; doubts about using the full CFI at the beginning of an evaluation; repetitiveness; difficulty engaging patients with severe illness; and lack of clinician buy-in, which may mostly reflect lack of familiarity with the CFI.”

• cites [17] sourceSupported

May combine two claims.

Family members accompanied all patients in Kenya, whereas no relatives went to interviews in Canada and the United States.

“Family members accompanied all patients in Kenya, whereas no relatives went to interviews in Canada and the United States, perhaps reflecting differences in family-versus individual-oriented care and support in these settings.”

• cites [25] sourceSupported

Classified as probably not a substantial claim.

Video presentations were deemed to be less helpful because they did not demonstrate how to work with uncooperative patients.

“Video presentations were deemed to be less helpful Focus Vol. 18, No. 1, Winter 2020 focus.psychiatryonline.org43 because they did not demonstrate how to work with uncooperative patients.”

• cites [26] sourceSupported

May combine two claims.

An initial, 14-item version of the CFI was tested; based on field trial results, it was then revised to produce the final 16-item version included in DSM-5.

“An initial, 14-item version of the CFI was tested; based on field trial results, it was then revised to produce the final 16-item version included in DSM-5.”

• cites [7] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Direct assessment of the potential effects of the CFI on communication, engagement, diagnostic accuracy, and treatment participation is only now under way.

“However, direct assessment of these potential effects is only now under way (11).”

• cites [11] sourceNot checked — no full text of the source

May combine two claims.

The CFI was clinically useful for diagnosis and treatment planning, decreased mistrust during the session, and helped to elicit information about patients' social networks and support.

“The authors found that the CFI was clinically useful for diagnosis and treatment planning, decreased mistrust during the session, and helped to elicit information about patients' social networks and support.”

• cites [14] sourceNot checked — no full text of the source

May combine two claims.

Italian clinicians found that the CFI was helpful for clarifying the diagnosis, strengthening the therapeutic relationship, facilitating patient communication, and fostering adherence to treatment in their cases of immigrants to Italy from Morocco and Sierra Leone.

“Italian clinicians found that the CFI was helpful for clarifying the diagnosis, strengthening the therapeutic relationship, facilitating patient communication, and fostering adherence to treatment in their cases of immigrants to Italy from Morocco and Sierra Leone (22).”

• cites [22] sourceNot checked — no full text of the source

May combine two claims.

The CFI led the clinical team to appreciate cultural and familial meanings of stomachache in one case and led to active involvement of the mother in the second, leading to breakthroughs in treatment, drawing attention to potential predicaments of Ethiopians in Israeli society, bringing to awareness clinical information that was previously neglected, and causing the treating team to question

“The CFI led the clinical team to appreciate cultural and familial meanings of stomachache in one case and led to active involvement of the mother in the second-both of these applications led to breakthroughs in the treatment, drew appropriate attention to potential predicaments of Ethiopians in Israeli society, brought to awareness clinical information that was previously neglected, and caused the”

• cites [21] Grundman Shem-Tov R, 2018, Isr J Psychiatry Relat SciNot checked — no full text of the source

May combine two claims.

The CFI elicited data that augmented culturally responsive care by bringing to attention what mattered most to Hispanic patients in an ethnic-focused clinic in New Haven, Connecticut: establishing relationships of trust with caregivers, addressing the stigma of mental illness, and paying attention to family-and church-related matters.

“Yet another research team found that the CFI elicited data that augmented culturally responsive care by bringing to attention what mattered most to Hispanic patients in an ethnic-focused clinic in New Haven, Connecticut: establishing relationships of trust with caregivers, addressing the stigma of mental illness, and paying attention to family-and church-related matters (16).”

• cites [16] sourceNot checked — no full text of the source

May combine two claims.

Drawing from the CFI field trial data from Lima, Peru, the main positive outcomes had to do with improved clinical communication: patients felt listened to and better understood by their doctors; the CFI enabled honest discussions about prejudice among ethnic groups and about religious beliefs, such as bewitchment, as a cause of illness; and the CFI gave permission to patients to frankly express,

“Drawing from the CFI field trial data from Lima, Peru, the authors noted that the main positive outcomes had to do with improved clinical communication: patients felt listened to and better understood by their doctors; the CFI enabled honest discussions about prejudice among ethnic groups and about religious beliefs, such as bewitchment, as a cause of illness; and the CFI gave permission to”

• cites [19] Alarcon RD, 2016Not checked yet

  Not checked in the free run.

May combine two claims.

Studies on the effectiveness of the CFI to improve clinical outcomes are lacking, and this paucity of data points to an urgent research priority.

“However, studies on the effectiveness of the CFI to improve clinical outcomes are lacking, and this paucity of data points to an urgent research priority.”

Probably not a substantial claim: may not pass S4 (based).

To date, most studies of the CFI have been authored by a small group of researchers and academics, mostly from North America, who were involved in the DSM-5 field trials.

“To date, most studies of the CFI have been authored by a small group of researchers and academics, mostly from North America, who were involved in the DSM-5 field trials.”

Probably not a substantial claim: may not pass S4 (based).

Since the publication of the CFI as part of DSM-5 in 2013, the literature on its use in training and clinical work has grown.

“Since the publication of the CFI as part of DSM-5 in 2013, the literature on its use in training and clinical work has grown.”

May combine two claims.

Understanding a patient's illness narrative depends on situating it in social and cultural context, and this may be particularly challenging when patient and clinician come from different backgrounds.

“Understanding this narrative depends on situating it in social and cultural context, and this may be particularly challenging when patient and clinician come from different backgrounds (1).”

• cites [1] sourceNot checked — no full text of the source

May combine two claims.

The CFI raised issues of mistrust of whites in the interview of a Somali-American child and enabled the development of a more nuanced treatment plan that incorporated religious practice and family involvement.

“In their research, the authors found that the CFI raised issues of mistrust of whites in the interview of a Somali-American child and enabled the development of a more nuanced treatment plan that incorporated religious practice and family involvement.”

• cites [24]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

For psychiatry residents, the CFI can be used to foster the development of skills in clinical interviewing and patient-centered care.

“For psychiatry residents, the CFI can be used to foster the development of skills in clinical interviewing and patient-centered care.”

• cites [32] Lim RF, 2016 sourceNot checked — no full text of the source

May combine two claims.

Residents appreciated the opportunity to practice the CFI questions, and the CFI questions acted as scaffolds for the residents to build better understanding of health disparities, biases in clinical work, and culture-related attitudes that may affect patient outcomes.

“Generally, the residents appreciated the opportunity to practice the CFI questions, and the investigators found that the CFI questions acted as scaffolds for the residents to build better understanding of health disparities, biases in clinical work, and culturerelated attitudes that may affect patient outcomes.”

• cites [28] sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

The CFI focus on individual experience in context may counteract the tendency to present cultural information in terms of stereotypes and may help students develop a systemic perspective on patients' circumstances.

“The CFI focus on individual experience in context may counteract the tendency to present cultural information in terms of stereotypes and may help students develop a systemic perspective on patients' circumstances.”

• cites [32] Lim RF, 2016 sourceNot checked — no full text of the source

May combine two claims.

Patients with severe symptoms, including acute psychosis, suicidal behavior, and aggression, and those with acute disabilities, such as cognitive impairment, may not be able to complete the CFI.

“Patients with severe symptoms, including acute psychosis, suicidal behavior, and aggression, and those with acute disabilities, such as cognitive impairment, may not be able to complete the CFI (7).”

• cites [7] sourceNot checked — no full text of the source

May combine two claims.

Small-group objective structured clinical examinations for teaching use of the CFI enhanced trainees' comfort in using the CFI, improved their knowledge of cultural syndromes, and refined their diagnostic skills by helping them differentiate between acceptable religious practices and religious behaviors associated with psychosis.

“Another team described the use of small-group objective structured clinical examinations for teaching use of the CFI and found that this approach enhanced trainees' comfort in using the CFI, improved their knowledge of cultural syndromes, and refined their diagnostic skills by helping them differentiate between acceptable religious practices and religious behaviors associated with psychosis (31).”

• cites [31] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

An educational assessment can help clarify the context of clinical findings.

“Second, when facing communication difficulties, an educational assessment can help clarify the context of clinical findings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The CFI may not always stand alone but may be used as one component of a broader approach to cultural formulation.

“The CFI may not always stand alone but may be used as one component of a broader approach to cultural formulation.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some patients may feel uncertain about the purpose of the CFI interview and may find some questions difficult because of shame, stigma or loss of face, or family honor.

“Third, although many patients appreciate the CFI's focus on their personal experience, some patients may feel uncertain about the purpose of the interview.They may find some questions difficult because of shame, stigma or loss of face, or family honor.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The quality of information obtained by the CFI and its ability to increase clinical rapport depend on good clinical communication.

“First, the quality of information obtained by the CFI and its ability to increase clinical rapport depend on good clinical communication.”

Probably not a substantial claim: may not pass S4 (based).

For most patients, information from other family or community members is needed to clarify the social context and to assess family and community networks.

“Fourth, for most patients, information from other family or community members is needed to clarify the social context and to assess family and community networks.”

Classified as probably not a substantial claim.

The CFI key informant version can identify sources of stress and resilience factors as well as caregiver issues that need to be addressed.

“This can identify sources of stress and resilience factors as well as caregiver issues that need to be addressed.”

Classified as probably not a substantial claim.

The components of the CFI are too dependent on adult communication capabilities to be used with children.

“In a case study, La Roche and Bloom (24) found that the components of the CFI were too dependent on adult communication capabilities to be used with children.”

• cites [24]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Patients with little formal schooling may have limited literacy and find it difficult to answer overly broad, abstract, or open-ended questions.

“Patients with little formal schooling may have limited literacy and find it difficult to answer overly broad, abstract, or open-ended questions.”

May combine two claims.

Some of the material elicited by the CFI in the New Haven clinic would not have been uncovered without the CFI, which would have undermined the care of patients.

“The authors judged that some of this material would not have been uncovered without the CFI, which would have undermined the care of patients.”

• cites [16] sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The CFI-Informant Version and supplementary modules can provide residents with tools to elicit cultural material throughout their clinical practice.

“The CFI-Informant Version and supplementary modules, which could be introduced in core training sessions or in elective cultural psychiatry rotations, can provide residents with tools to elicit cultural material throughout their clinical practice.”

• cites [32] Lim RF, 2016 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The authors considered that these factors facilitated recovery in these patients who had previously been difficult to help.

“The authors considered that these factors facilitated recovery in these patients who had previously been difficult to help.”

• cites [21] Grundman Shem-Tov R, 2018, Isr J Psychiatry Relat SciNot checked — no full text of the source

May combine two claims.

The CFI usefully enhances rapport and yields meaningful clinical information when used with individuals with chronic psychosis.

“The authors concluded that the CFI usefully enhances rapport and yields meaningful clinical information when used with individuals with chronic psychosis.”

• cites [15] sourceNot checked — no full text of the source

May combine two claims.

Use of the CFI not only sensitizes clinicians to the cultural issues of individual patients but can also contribute to the evaluation of clinical programs by highlighting problem areas and adapting the delivery of interventions to the cultural needs of patients and their families.

“Importantly, the New Haven experience suggested that use of the CFI not only sensitizes clinicians to the cultural issues of individual patients but can also contribute to the evaluation of clinical programs by highlighting problem areas and adapting the delivery of interventions to the cultural needs of patients and their families.”

• cites [16] sourceNot checked — no full text of the source

May combine two claims.

An interview with an interpreter present can suggest diagnostic changes or can bring relief to patients who have been unable to communicate for prolonged periods.

“An interview with an interpreter present can suggest diagnostic changes or can bring relief to patients who have been unable to communicate for prolonged periods.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Multicultural assessment includes the CFI along with other instruments and procedures.

“Multicultural assessment (35), an approach developed specifically for clinical psychologists, includes the CFI along with other instruments and procedures.”

• cites [35] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Widespread use of the CFI can contribute to more respectful clinical interaction and more inclusive care for all in psychiatry and the mental health professions, as well as in general health care and social services.

“Widespread use of the CFI can contribute to more respectful clinical interaction and more inclusive care for all-in psychiatry and the mental health professions, as well as in general health care and social services.”

Probably not a substantial claim: may not pass S2 (checkable).

Responding to issues of structural violence and marginalization is essential to achieve health equity.

“Responding to issues of structural violence and marginalization is essential to achieve health equity (39).”

• cites [39] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

In its current form, the CFI provides a simple way to begin the process of cultural assessment, and its systematic use can foster a reflective stance and promote systemic thinking about the patient's life world.

“Future research may suggest additional refinements, but in its current form it provides a simple way to begin the process of cultural assessment, and its systematic use can foster a reflective stance and promote systemic thinking about the patient's life world, which otherwise may be hard to establish in routine clinical practice.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some researchers have called for caution and warned of the risk of stereotyping and simplifying cultural material when using the CFI.

“Some researchers have called for caution and warned of the risk of stereotyping and simplifying cultural material when using the CFI (36).”

• cites [36] sourceNot checked — no full text of the source

May combine two claims.

Conducting an ICD requires staff members with high levels of cultural and clinical experience, as well as the time to hold an intensive case discussion.

“However, conducting an ICD requires staff members with high levels of cultural and clinical experience, as well as the time to hold an intensive case discussion.”

• cites [36] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

ICDs represent a check on possible misuse of the CFI by those who lack experience or training.

“ICDs represent a check on possible misuse of the CFI by those who lack experience or training.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

ICDs broadened the scope of clinical data collection, eschewed simplistic assignments of cultural identity, and brought to the discussion structural issues that may perpetuate stigma, inequity, and 'othering' of immigrants and refugees.

“More specifically, ICDs broadened the scope of clinical data collection, eschewed simplistic assignments of cultural identity, and brought to the discussion structural issues that may perpetuate stigma, inequity, and”

• cites [36] sourceNot checked — no full text of the source

May combine two claims.

Training is straightforward, and even one hour of training conveys measurable benefits to students.

“Training is straightforward, and even one hour of training conveys measurable benefits to students.”