Clinician tool
Cultural formulation guide
About the Cultural Formulation Interview
The Cultural Formulation Interview (CFI) is a set of 16 questions in the core CFI, published in DSM-5, that helps you assess the impact of culture on a person’s clinical presentation and care. It is person-centered by design: it asks the client to explain their own experience in their own words and deliberately avoids assuming anything from a person’s background — the goal is understanding this individual, not applying stereotypes about a group.
Culture is understood broadly here. It includes ethnicity, race, religion and spirituality, language, gender identity and sexual orientation, immigration and refugee status, socioeconomic status, ability and disability, and more — any of the many communities and contexts that shape how a person understands and lives with distress.
1. Cultural Definition of the Problem
Elicit the person’s own framing of what is wrong, in their words, before applying any clinical label.
- What brings you here today? What is troubling you most?
- People often understand their problems in their own way. How would you describe your problem to family, friends, or others from your community?
- Sometimes people have different ways of describing their problem to their doctor. How would you describe it to me?
- Of the things you have described, which troubles you the most?
2. Cultural Perceptions of Cause, Context, and Support
Explore what the person believes is causing the problem, what makes it better or worse, the supports around them, and how their background and identity relate to it.
Causes
- Why do you think this is happening to you? What do you think are the causes?
- What do others in your life — family, friends, others — think is causing your problem?
Stressors & Supports
- Are there any kinds of support that make your problem better, such as from family, friends, or others?
- Are there any kinds of stresses that make your problem worse, such as difficulties with money, work, or family?
Role of Cultural Identity
- For you, what are the most important aspects of your background or identity?
- Are there any aspects of your background or identity that make a difference to your problem?
- Are there any aspects of your background or identity that are causing other concerns or difficulties for you?
3. Cultural Factors Affecting Self-Coping and Past Help-Seeking
Understand what the person has already tried on their own and the range of help they have sought — professional, family, community, and traditional or religious — including what helped and what got in the way.
- Sometimes people have various ways of dealing with problems like yours. What have you done on your own to cope?
- Often people look for help from many different sources. What kinds of help or treatment have you sought — from family and community, from traditional or religious healers, or from other providers?
- What types of help or treatment were most useful? What was not useful?
- Has anything prevented you from getting the help you need — for example, cost, insurance, transportation, time, language, or worries about being judged?
4. Cultural Factors Affecting Current Help-Seeking
Clarify what the person wants now, surface any barriers, and name how the two people in the room — their backgrounds and expectations — may shape the work together.
- Now let us talk some more about the help you need. What kind of help would be most useful to you at this time?
- Are there other kinds of help that your family, friends, or community have suggested would be helpful for you now?
- Sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about this, and is there anything we can do to give you the care you need?
- Is there anything about our backgrounds — mine or yours — that might affect our work together, or make it harder to get the care you need?
Cultural identity factors to explore
Identity is layered and personal. Explore these dimensions with curiosity, and let the client tell you which matter most to them and how.
- Race and ethnicity
- National origin and place of birth
- Language(s) spoken and preferred; need for a trained interpreter
- Religion, spirituality, and faith community
- Gender identity and sexual orientation
- Age and generation (including generational status)
- Immigration, refugee, and acculturation status
- Socioeconomic status, income, and education
- Ability and disability
- Occupation and work context
- Geographic and rural–urban context
- Family structure and roles
Cultural conceptualizations of distress
DSM-5 describes three overlapping ways culture shapes how distress is understood and expressed. The same symptom can be experienced, named, and explained very differently across cultures — for instance, distress may present largely through the body (somatic complaints) rather than through emotional language.
Cultural syndromes
Clusters of symptoms that tend to co-occur and are recognized as a coherent pattern within a particular cultural group.
For example, ataque de nervios — an episode of intense emotional upset — is recognized in some Latino communities.
Cultural idioms of distress
Shared ways of talking about or expressing suffering — the words and metaphors a community uses for a range of difficulties.
For example, describing distress as “nerves,” “thinking too much,” or as pain and heaviness in the body.
Cultural explanations / perceived causes
Explanatory models for why the problem is happening — its cause, mechanism, and expected course.
For example, attributing symptoms to stress, spiritual causes, an imbalance, fate, or an event in one’s life.
Psychosocial stressors, vulnerability & resilience
Culture shapes both the burdens a person carries and the strengths they draw on. Ask about each side.
Stressors & vulnerability
- Discrimination, racism, and marginalization
- Acculturation stress and intergenerational conflict
- Migration, displacement, and pre- or post-migration trauma
- Poverty, housing instability, and food insecurity
- Family separation and loss of social networks
- Language barriers and difficulty accessing services
Protective & resilience factors
- Faith community and spiritual practices
- Extended family and kinship support
- Cultural pride, identity, and connection to heritage
- Collective and community-based coping
- Bilingual or bicultural strengths and adaptability
- Rituals, traditions, and shared meaning
Cultural features of the clinician–patient relationship
The relationship itself is a cultural encounter. Attending to it is part of the formulation.
Power dynamics. Notice differences in power, authority, and social position between you and the client, and how they may shape what the client feels able to say.
Language & interpreters. Use a trained professional interpreter rather than family members or children. Ask the interpreter to interpret in the first person, speak to and look at the client (not the interpreter), and allow extra time.
Potential for misunderstanding. Different expectations about roles, diagnosis, and treatment can lead to misunderstanding. Check meaning rather than assuming it.
Clinician self-reflection. Reflect on your own culture, assumptions, and implicit bias, and how they may influence assessment and rapport.
Matching vs. mismatch. Shared or differing backgrounds each carry both strengths and blind spots — neither guarantees understanding nor prevents it.
Building trust. Curiosity, humility, and openness to being corrected build the trust that makes honest conversation possible.
Supplementary CFI modules
Beyond the core interview, DSM-5 offers supplementary modules that expand on specific topics or adapt the CFI for particular populations. Draw on them as the clinical situation calls for it:
- Explanatory Model
- Level of Functioning
- Social Network
- Psychosocial Stressors
- Spirituality, Religion, and Moral Traditions
- Cultural Identity
- Coping and Help-Seeking
- Patient–Clinician Relationship
- School-Age Children and Adolescents
- Older Adults
- Immigrants and Refugees
- Caregivers
A note on cultural humility
Cultural humility is a lifelong stance rather than a box to check. It is not a state of “competence” to be achieved and then set aside — it is an ongoing commitment to self-reflection, to learning from each person, and to noticing the limits of your own perspective. The CFI works best when it is held this way: as an invitation to keep listening, not a form to complete.