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Social workers know the principles of logic, scientific inquiry, and culturally informed and ethical approaches to building knowledge. After completing this week’s readings, write a critical reflection paper on the paradigm shifts between previous editions of the DSM and the DSM-5. The critical reflection should include:

The purposes of diagnosing including why social workers understand theories of human behavior and the social environment, and critically evaluate and apply this knowledge to effectively intervene with clients and constituencies.

An identification of the problems related to DSM III and DSM IV that prompted the move to DSM-5.

Discussion of the new diagnosing scheme for DSM-5. Explain how these recovery paradigms are applied to those suffering severe mental illness.

ORIGINAL PAPER Clinician Reasoning in the Use of Cultural Formulation to Resolve Uncertainty in the
Diagnosis of Psychosis Ademola B. Adeponle • Danielle Groleau • Laurence J. Kirmayer Published online:
14 October 2014 Springer Science+Business Media New York 2014 Abstract We examined how the
process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders
at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process
used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the
CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case
conference transcripts was used to identify clinicians’ reasoning styles. Use of the CF appears to
facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize
the diagnosis of the intake ‘psychosis’ symptoms or behavior; (ii) elaborate explanations as to why the
symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or reinterpret as non-psychosis. Prototypes and exemplars Preliminary findings of the study were presented
at the 2011 annual conference of the Society for the Study of Psychiatry and Culture held in Montreal,
Quebec. The study was completed as part of the fulfillment of the requirements for the M.Sc. by the first
author. A. B. Adeponle (&) Division of Social & Transcultural Psychiatry, Department of Psychiatry,
McGill University, Montreal, QC, Canada e-mail: ademola.adeponle@mail.mcgill.ca A. B. Adeponle D.
Groleau L. J. Kirmayer Culture and Mental Health Research Unit, Lady Davis Medical Institute, Jewish
General Hospital, 4333 Cote St. Catherine Rd., Montreal, QC H3T 1E4, Canada D. Groleau e-mail:
danielle.groleau@mcgill.ca L. J. Kirmayer e-mail: laurence.kirmayer@mcgill.ca D. Groleau L. J. Kirmayer
Division of Social & Transcultural Psychiatry, McGill University, Montreal, QC, Canada 123 Cult Med
Psychiatry (2015) 39:16–42 DOI 10.1007/s11013-014-9408-51 drawn from previous experience in
intercultural work featured prominently in clinicians’ reasoning. Prototypes were crucial in diagnostic
decision-making and appear to be important sources of both clinician expertise and bias, and may need
to be targeted specifically in cultural competence training. Keywords Cultural formulation Psychosis
diagnosis Clinician reasoning and bias Immigrants and refugees Cultural competence Introduction In
North America, misdiagnosis of psychiatric disorders (including non-recognition, misidentification, and
over-diagnosis) is common, and occurs among all ethnoracial groups, including immigrant and refugee
patients (Gara et al. 2012; Lin et al. 2012; Lukachko and Olfson 2012; Kirmayer et al. 2011; Williams and
Earl 2007; Good 1993). Misdiagnosis has been explained in terms of clinician bias, leading to
inadequacies in the way clinicians collect and interpret clinical information of patients (Dovidio and Fiske
2012; van Ryn et al. 2011; Burgess et al. 2007; 2010; Hays et al. 2010; Snowden Snowden 2003;
Strakowski et al. 2003; Lopez 1989). A more recent finding is that ethnic differences in psychiatric
diagnosis may arise because clinicians attribute and interpret symptoms differently for patients as a
matter of clinical judgment (Dovidio and Fiske 2012; Hays et al. 2010; Muroff et al. 2008; Trieweiler et al.
2000, 2005). However, much of the literature on clinical judgment and decision-making is theoretical or
involves experimental studies, and there is a paucity of naturalistic studies on decision-making process
in diagnostic practice. Intercultural clinical work, in which clinicians must assess clients from
backgrounds that differ widely from their own, poses special challenges. No gold standard method exists
for diagnosis in cross-cultural settings. Although investigators have traditionally advocated for the use of
structured interviews and strict diagnostic criteria as a way to reduce biases that may occur in clinical
settings studies indicate that neither approach yields more accurate diagnosis or eliminates clinician bias
(Lewis-Fernandez and Aggarwal 2013; Alarco´n et al. 2009; Alarco´n 2009; Neighbors et al. 1999; Loring
and Powell 1988). More recent studies emphasize the need to increase clinician cultural competence
and call for research on the ways that subjective biases (i.e., individual’s dispositions related to or
stemming from their emotions, stereotypes of patients, or prejudices) influence clinicians’ judgments in
diagnostic decision-making (Payne 2012; van Ryn et al. 2011; Hays et al. 2010; Burgess et al. 2010;
Neighbors et al. 2003). The Outline for Cultural Formulation (OCF) introduced in DSM-IV (APA 1994) for
use by clinicians as guide to cross-cultural assessments represents an important step actualize cultural
competence (Lewis-Fernandez and Aggarwal 2013; Alarco´n et al. 2009; Mezzich et al. 1999, 2009;
Lewis-Fernandez and Kleinman 1995; Kirmayer 1998). The recently released DSM-5 (American
Psychiatric Association 2013) includes an updated version of the OCF and an approach to its application
in clinical assessments, the Cultural Formulation Interview (CFI). The CF outline has five sections that
cover a broad assessment of the role culture and context have on Cult Med Psychiatry (2015) 39:16–42
17 1232 illness presentation and on the diagnostic process itself: (i) cultural identity, (ii) illness
explanations, (ii) factors in social environment, (iv) cultural aspects of clinician-patient interactions, and
(v) overall formulation, (Fernandez and Diaz 2002). The CF is rooted in a view of diagnosis as a social
practice and of psychiatric disorders as manifestations of the interactions of biological, psychological,
environmental, and sociocultural factors (Kirmayer 1998). Reports from clinicians who make use of the
CF in their work with immigrant and ethnic minority patients suggest it is a useful tool in patient
assessments and diagnostic clarification (Kirmayer et al. 2014; Rosso and Ba¨a¨rnhielm 2012; Dinh et al.
2012; Bennett 2009; Kirmayer et al. 2008; Fortuna et al. 2009; Rohlof et al. 2009; Martinez 2009). There
is a dearth of information on the actual process of applying the CF including the clinical judgment
strategies and reasoning process clinicians apply in the assessment of ethnic minority and immigrant
patients (Aggarwal et al. 2013; Mezzich et al. 2009). Attention to cultural issues can divert attention
from social structural and economic problems (Corin 1997; Kleinman and Benson 2006). A continuing
concern in cross-cultural work with ethnic minority and immigrant patients is that clinicians might use
the CF in a way that privileges culturally essentialist explanations over considerations of the material
conditions of patients (Kleinman and Benson 2006; Good et al. 2011; Kirmayer 2012). Until the recent
introduction of the CFI in DSM-5, the Cultural Formulation outline was presented without guidelines as
to its actual application to clinical assessment and case formulation. Great latitude in use of the CF was
left to the clinicians’ discretion, which might introduce inconsistencies and bias in its application and
interpretation. Since much of the empirical research on clinician bias in intercultural psychiatric
assessment points to the influence on clinicians of negative stereotypes of ethnic minority patients (e.g.,
African American men viewed as ‘‘angry’’ or ‘‘dangerous’’1 ) as a cause of psychosis misdiagnosis, it is of
particular interest to examine how the use of CF influences diagnostic decision-making in this context.
Study Objectives The present study examined the process of cultural formulation in the diagnostic
reassessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS)
(Kirmayer et al. 2003, 2014). The main research question was to understand how the process of cultural
formulation contributes to diagnostic reassessment and, more specifically, what styles of reasoning
clinicians use to rule in or out psychosis, and what role social and cultural information obtained through
the cultural assessment plays in the process of diagnostic reassessment. More specifically, we set out to
describe the reasoning process by 1 Metzl (2009) provides a gripping account of how in the wake of
psychiatric deinstitutionalization and black civil rights agitations in the 1960s US, the diagnostic label
‘schizophrenia’ previously used as preferred diagnostic label for white middle-class women morphed
radically into a diagnostic label applied preferentially to young, poor, black males. Metzl traces the
origins of the stereotype of young, black male patients as dangerous, angry, criminal and as coming to
clinical attention through police and other coercive methods, to this period in the history of America and
American psychiatry. 18 Cult Med Psychiatry (2015) 39:16–42 123 which symptoms identified as
psychotic in routine clinical settings are confirmed as psychotic or re-interpreted as non-psychotic in the
process of cultural formulation. Theoretical Foundations: Clinician Reasoning and Judgment In this
section, we present a synopsis of the theoretical approach to clinician reasoning and diagnostic
judgment in social and cognitive psychology, and in studies of medical decision-making. Investigators
have proposed the existence of two kinds of reasoning systems in clinical problem solving and decisionmaking (Mamede et al. 2010, 2012; Norman and Eva 2010; Norman et al. 2007; Mamede et al. 2007; De
Neys 2006). The first, nonanalytical reasoning (also called the heuristic system) is fast, automatic and
associative, and functions as the default system of reasoning. In heuristic reasoning, the individual relies
on prior knowledge and beliefs to solve a problem and make decisions. The second system, hypotheticodeductive or analytic reasoning, is controlled, effortful, and rule-governed (Norman and Eva 2010; Balla
et al. 2009; De Neys 2006). Both novice and experienced physicians are adept at deploying analytical
reasoning, but adroitness in use of heuristic reasoning is a key feature of diagnostic expertise (Mamede
et al. 2010; Norman et al. 2007). In studies of decision-making, dual-process theories (Kahneman et al.
1982; Kahneman 2011) integrate heuristic and analytic models, and posit that under optimal conditions,
the two systems act in concert (Pelaccia et al. 2011; De Neys, 2006). The task of medical diagnosis is
essentially one of categorization (Pelaccia et al. 2011; Custers et al. 1996). This may involve rule-based
categories, in the case of analytical reasoning, and in the case of non-analytic reasoning, categories that
are based on the use of prototypes (that is, representations of typical patients in the clinician’s
memory), exemplars (instance-based representations, i.e., actual memories of previously seen patients),
and illness scripts (i.e., specific, goal-directed knowledge structures) (Pelaccia et al. 2011; Norman et al.
2007; Garb 2005; also see: Kim and Ahn 2002; Custers et al. 1996). According to prototype theory, a
prototype of a category is an averaged representation of a person’s experience with individual
exemplars of the category that contains most of the critical (typical) features of the category. So, when a
new object is presented, categorization occurs by identifying the category in memory that has most
features in common with the new object. Exemplar theory, on the other hand, holds that over time
people acquire a large pool of exemplars of each natural category; thus, when presented with a new
object, they are able to categorize by making a similarity match with a particular prior example of the
category held in their memory (Norman et al. 2007). Scripts are abstract cognitive structures, integrated
networks of prior knowledge people use to help make sense of novel situations (Charlin et al. 2007).
According to script theory, scripts are goal-directed schemas that arise from repeated experiences of
real world events, such that the sequence of activities related to the particular experience or event
come to be organized in specific ways with corresponding expectations, inferences, and actions. When a
person is presented with new information it leads to activation of the previously acquired network of
relevant Cult Med Psychiatry (2015) 39:16–42 19 123 knowledge and experience, which may be
organized as a script—and it is this activated script that directs the selection, interpretation, and
memorization of that new information (Charlin et al., 2000). Expectations and actions embedded in
scripts allow clinicians to (i) make predictions about features (symptoms, signs, and contextual factors
from patient’s environment and background) that may be encountered in a situation, (ii) check these
features in order to adequately interpret (classify) the situation, and (ii) act appropriately (Charlin et al.
2007). When clinicians deal with problems that are complex, ambiguous or unusual, nonanalytical
reasoning functions less robustly and can become more error-prone (Mamede et al. 2010; De Neys
2006). Under such circumstances, clinicians may switch to the use of more reflective analytical
reasoning. John Dewey (1933), who is credited with linking reflection to improvement of practice
(Mamede and Schmidt 2004), saw reflective thought as a five stage process: (i) a state of doubt or
uncertainty due to emergent difficulty in understanding an event or solving a problem; (ii) definition of
the difficulty by thoroughly understanding its nature; (iii) development of a suggested explanation or
possible solution for the problem, through inductive reasoning; (iv) rational elaboration of the ideas
produced through abstract, deductive thought focusing on their implications; and (v) testing the
resulting hypotheses by overt or imaginative action. Mamede and co-workers (Mamede et al. 2012;
Mamede and Schmidt 2004; Mamede et al. 2007) extended Dewey’s ideas with their concept of
reflective practice, or deliberate practice, which they refer to as the ‘‘preparedness of doctors to think
critically and engage in a scrutiny of their own reasoning and decisions’’ (Mamede et al. 2007, p. 1186).
Mamede and co-workers (2004, 2012) propose a 5-factor model of the structure of reflective practice:
(i) deliberate induction; (ii) deliberate deduction; (iii) testing generated hypotheses against problem at
hand; (iv) an attitude of openness toward reflection; and (v) meta-reasoning (the ability to think about
one’s own processes and to critically review one’s own assumptions or beliefs regarding a problem).
Research in cognitive psychology suggests that when the information obtained by clinicians does not fit
with existing normative categories (e.g., prototypes or scripts), the resultant diagnostic uncertainty
prompts the use of judgment heuristics (cognitive shortcuts) as the clinician seeks to reconcile the
variance between the information given by the patient and the normative representations of diagnoses
(Pelaccia et al. 2011; Garb 2005; Whaley and Geller 2007). Under these conditions, misdiagnosis can
occur because of two social cognitive processes: (i) correspondent inference (the tendency to quickly
associate observed behavior with internal dispositions); and (ii) the tendency to assume that behavior
across situational circumstances is caused by factors within or characteristics of the person, i.e.,
clinicians’ inattention to the role of situational factors (Trierweiler et al. 2005). Methods The present
report is part of a larger study of determinants of change in the diagnosis of psychosis among patients
seen at the CCS at the Jewish General Hospital, Montreal (Adeponle et al. 2012). 20 Cult Med Psychiatry
(2015) 39:16–42 123 Setting The CCS is a specialized mental health service located in the outpatient
psychiatry department of the Jewish General Hospital (JGH) in Montreal. Established in 1999, the CCS
aims to improve the accessibility and cultural appropriateness of mental health services for the
multicultural population of the greater Montreal region, including immigrants, refugees, and
ethnocultural groups (Kirmayer et al. 2014). To that end, the CCS provides: (1) cultural psychiatric
consultation; (2) information resources for multicultural mental health; and (3) training to mental health
professionals for intercultural work. The JGH is a community hospital associated with McGill University
located in a multiethnic inner-city neighborhood of Montreal with a large population of newly-arrived
immigrants and refugees of varied social economic status. The CCS uses a consultation-liaison model and
emphasizes integrating medical anthropology perspectives with psychiatric, cognitive-behavioral, and
family systems perspectives (Kirmayer et al. 2003, 2014). The service receives referrals from primary
care, mental health care, and other health professionals for help with clarification of diagnosis,
treatment planning, problems in treatment adherence, or other cultural issues in clinical care. Although
a specialized service, the CCS does not take over the care of referred patients, but supports and
collaborates with existing services and practitioners in mental health, psychiatry, and primary care. This
approach is consistent with the values of Canadian multiculturalism, which aims to recognize and
respond to cultural diversity within mainstream institutions (Kirmayer et al. 2003). The core CCS team
comprises a full-time clinical coordinator who triages all referred cases, 3 part-time psychiatrists, and a
network of interpreters and ‘culture brokers’ (cultural consultants) who are generally mental health
professionals (psychologists, social workers, psychiatric nurses), medical anthropologists, and other
persons knowledgeable about specific cultural communities (Kirmayer et al. 2003, 2008, 2014). Cultural
consultation typically entails (i) initial assessments of the patient by the CCS consultant (in most cases, a
psychiatrist) and by a culture broker, with or without an interpreter in attendance, and (ii) a case
conference, convened to facilitate a multidisciplinary assessment of the patient’s illness (Dinh et al.
2012; Kirmayer et al. 2014). At the initial assessment, the CCS psychiatrist usually conducts the patient
assessment, with the assistance of a culture broker who clarifies the cultural context of the patient’s
illness. The culture broker may interview patients or members of their entourage without the
psychiatrist present if more cultural background information is required. After the interviews, the
culture broker prepares a report following an expanded version of the DSM-IV-TR outline for cultural
formulation (Kirmayer et al. 2008). The case is then discussed at a clinical case conference which is
attended by the CCS consultants, culture broker, professionals and trainees in psychiatry, psychology,
anthropology, and other social sciences. The referring clinician is invited to the case conference, but
usually cannot attend due to other work commitments. The CCS case conference follows a standard
format: (i) the attending CCS consultant opens the meeting and presents the case, with input from
referring clinicians as needed; (ii) the culture broker then presents a cultural formulation report; (iii) this
is followed by open discussion and deliberation by all present at the meeting; Cult Med Psychiatry
(2015) 39:16–42 21 123 and (iv) the CCS consultant distils key points that emerge from the discussion
and ends the meeting with a summary of recommendations. Case conferences are routinely audiorecorded and transcribed as part of an ongoing research protocol. The recordings and transcripts of
these meetings provided the data for our study. Participants at the CCS Case Conference The CCS case
conferences are chaired by the psychiatrist who directs the service. He is of Euro-Canadian descent and
speaks both French and English. Invited participants include the culture broker, referring clinician, and
others involved in the patients care. Regular participants include mental health clinicians (psychiatrists,
psychologists, social workers, nurses) at the hospital where the CCS is based and researchers (medical
anthropologists and sociologists) affiliated with the hospital’s Culture and Mental Health Research Unit;
other participants include psychiatric residents and health and social science students interested in
intercultural work. The service employs over 60 culture brokers who are generally mental health
professionals. They provide single consultations on a fee-for-service basis. Most are multilingual,
bicultural clinicians from diverse backgrounds in mental health or knowledgeable members of specific
ethnocultural communities (Dinh et al. 2012). All of the cases included in the analysis for this study did
not use language interpreters; instead, cultural brokers provided language interpretation when needed
and thus functioned in a dual role as linguistic and cultural interpreters. Data Data for the present study
were obtained from patient case files and case conference transcripts. Sampling was purposive (Pope
and Mays 1995), to select cases of patients with an intake (referral) diagnosis of a psychotic disorder
referred to the CCS primarily for reasons of diagnostic clarification. Only cases involving patients who
were immigrants from sub-Saharan Africa were included in the analysis since they constitute a sizeable
number of the cases referred to the CCS for reasons of diagnostic uncertainty, and previous research in
the U.S. and U.K. suggests that Black and African patients may be at risk for psychosis misdiagnosis
(Jarvis 2008). This resulted in a sample of 23 cases. For each case, the CCS psychiatric notes, culture
broker’s reports, and CCS meeting transcripts were reviewed to identify the symptom(s) and behavior(s)
labeled ‘psychosis’ by the referring clinician and the consultants. The CCS data were collected as part of
an ongoing research protocol that received ethics approval from the Institutional Review Board of the
Jewish General Hospital, Montreal. Participants gave informed consent to use the data for research. In
the excerpts from transcripts below details have been changed to protect patient anonymity. Analysis
Thematic analysis (Green and Thorogood 2004, p. 177) of the CCS case meeting transcripts was
conducted to identify how symptoms labeled psychotic by referring 22 Cult Med Psychiatry (2015)
39:16–42 123 clinicians were either confirmed as psychotic or re-interpreted as non-psychotic by the
CCS team. The thematic analysis of transcripts involved the following steps: i. identifying and coding
sentences, dialogs and exchanges in the CCS transcripts related to specific sections and items (i.e.,
themes) from the DSM-IV cultural formulation (CF) outline (American Psychiatric Association 1994, p.
898); ii. identifying the CF themes in the CCS case conference used to account for whether the labeled
symptoms/behavior was psychotic or not; iii. looking for patterns in how the CF themes identified were
used to determine whether or not the symptoms/behaviors were psychotic; and iv. looking for how the
observed pattern fit within the overall narrative structure or process of the CCS meeting. Transcriptions
were coded manually, line-by-line using inductive coding and open sampling (identifying portions in the
transcript that lead to greater understanding of the categories and their properties). As themes emerged
they helped guide analysis of subsequent cases until no new patterns emerged and saturation was
reached. Memos, detailing thoughts and observations on emerging data and categories were utilized
throughout the analysis. To ensure analytic rigor and representativeness of study findings, close
attention was paid to identifying deviant cases and exceptions within the data set. Each transcription
was initially coded by the first author (AB), and was later checked and discussed with the other authors
(DG, LK) as a further check on reliability of coding. Instances of disagreements were resolved by
discussion to achieve consensus. Results Thematic analysis was completed for 23 cases: (i) 11 cases in
which intake ‘psychosis’ symptoms/behavior, as identified by referring clinician, were reinterpreted as
non-psychosis by the CCS (the change in diagnosis group), and (ii) 12 cases in which the CCS confirmed
the intake ‘psychosis’ diagnosis (the no change in diagnosis group). Table 1 summarizes
sociodemographic characteristics of the two groups. In the change in diagnosis group, the principal CCS
diagnoses included post-traumatic stress disorder (PTSD) with prominent dissociative components (3
cases), PTSD (2 cases), major depression (4 cases), possible koro syndrome2 (1 case), and no disorder (1
case). For the no change in diagnosis group, CCS diagnoses were schizophrenia (6 cases), psychosis not
otherwise specified (NOS) (3 cases), major depression with psychotic features (2 cases), and bipolar
disorder with psychotic features (1 case). 2 Koro is a syndrome in which an individual has the belief his
penis is retracting into the abdomen, and that death will ensue if this is not halted (Buckle et al. 2007). It
occurs in sporadic and epidemic forms in a variety of cultures from Southeast Asia, the Indian
subcontinent and Africa. Cult Med Psychiatry (2015) 39:16–42 23 123 Reasoning Process Used to
Resolve Whether a Symptom or Behavior was Psychotic Thematic analysis revealed the use of a threestep process to resolve the question of whether a symptom or behavior was psychotic or not at the CCS
case conference. The three steps were: (i) problematize the intake ‘psychosis’ symptoms or behavior; (ii)
elaborate explanations on why the symptom or behavior may or may not be psychosis; and (iii) confirm
psychosis or re-interpret as non-psychosis. The three steps were used in sequence and iteratively (Fig.
1). The text-driven and conceptual categories (Table 2) that constitute the framework of the 3-step
process are described below using illustrative case excerpts. Table 1 Patient demographics, length of
stay, and immigration status in Canada Characteristic All patients (N = 23) Patients with change in
diagnosis (N = 11) Patients with no change in diagnosis (N = 12) n % n % n % Age (years) 20–29 9 39.0 4
36.0 5 41.0 30–39 12 52.0 6 55.0 6 50.0 C40 2 9.0 1 9.0 1 9.0 Gender Male 13 57.0 3 27.0 10 83.0 Female
10 43.0 8 73.0 2 17.0 Marital status Single 18 78.0 8 73.0 10 83.0 Married 5 22.0 3 27.0 2 17.0 Length of
stay (years) 2 12 52.0 8 72.0 4 33.0 2–5 7 31.0 2 18.0 5 42.0 [5 4 17.0 1 9.0 3 25.0 Immigration statusa
Non-PR 16 70.0 8 73.0 8 67.0 PR 7 30.0 3 27.0 4 33.0 Referral source Family doctor 11 48.0 7 63.0 4 33.0
Psychiatrist 8 35.0 3 27.0 5 42.0 Other 4 17.0 1 9.0 3 25.0 By patient’s country of origin, the 11 cases that
were re-interpreted as non-psychosis involved 5 patients from Nigeria, and one each from Cameroun,
Ethiopia, Sierra Leone, Congo DR, Kenya, and Somalia. The 12 cases confirmed as psychosis comprised
patients from Guinea (2), Nigeria (2), Ghana (2), Chad (2), Cameroun (2), Togo (1), and Senegal (1) a
Non-PR: refugee applicant, student and visiting visa, PR: landed immigrant, citizen, refugee/asylum
seekers 24 Cult Med Psychiatry (2015) 39:16–42 123 Problematization In the early stages of the CCS
meeting, participants engaged in a process of problematization of the diagnosis that involved describing
and clarifying the details of patient’s illness in 4 domains: (i) biomedical facts of the illness; (ii) social
contexts in which the illness occurred; (iii) meanings and attributions of the illness made by the patient;
and (iv) views of patient’s family and community about the illness. In problematization of the biomedical
facts of the illness, participants set out first to obtain a detailed description of symptoms (physical and
psychological) then use questioning to further clarify biomedical etiological contribution. The excerpt
below, of patient in whom a diagnosis of Koro syndrome was entertained illustrates this: Resident: His
main worries are his genitals… he is worried something bad will happen if the process of shrinking is not
stopped CCS Psychiatrist: The spinal stenosis you’re talking about, is it a real medical issue… and the pain
in the pelvis, how serious is it? Resident: What I have is just his statement that (it) was considered
serious enough to propose surgery CCS Psychiatrist: Is this a genetic thing that he was born with?
Symptom persistence, severity, associated symptoms, general medical Is biomedical causation
sufficient? Context, narrative, opinion of family/community Psychosis likely Is a psychosocial explanation
applicable? Confirm psychotic disorder Normative Contextual Misinterpretation Psychosis unlikely
Reinterpret Yes Yes No No Fig. 1 The flowchart depicts the 3-step reasoning process used at the CCS
meetings to resolve uncertainty of psychosis diagnosis. The topmost levels of the flowchart represent
the ‘‘problematization’’ step, in which the goal is to obtain as much information as possible (about
symptoms, context, narrative) to make the patient’s illness intelligible and amenable to input from the
expertise available at the CCS meeting. The middle portions of the flowchart represent the ‘‘elaborating
explanations’’ step, in which the goal is to raise questions about possible causation and provide reasons
why the (apparent) psychotic symptoms are either pathological or non-pathological. The bottom portion
of the flowchart represents the ‘‘confirm or re-interpret diagnosis’’ step, in which diagnosis of psychosis
is either confirmed or a diagnosis of non-psychosis made Cult Med Psychiatry (2015) 39:16–42 25 123 In
problematization of social contexts of illness occurrence, CCS meeting participants pose questions to
elucidate and clarify possible social causation, as in the excerpt below, of a woman with recurrent
nightmares, fearfulness, and auditory hallucinations: CCS Psychiatrist 1:… she began to have auditory
hallucinations of her (ex) husband and others telling her that she must die and they’ll take the baby, and
the fear of her husband became so intense she began to rarely leave the apartment… even here in
Montreal, she is afraid her husband may have friends or people here that will find her.. . CCS Psychiatrist
2: That’s another reason why she might think that he would, I mean, this is his child and presumably, he
might be interested in tracking her down? Culture Broker: Yeah, her in-laws told her they would take the
child and get rid of her CCS Psychiatrist 1: That’s why she became afraid, that once the baby was born,
anything could happen to her, she was useless kind of, and may be killed Table 2 Conceptual scheme
used to resolve uncertainty of psychosis diagnosis I. Make the illness experience intelligible
Problematization: describe and clarify 1. The medical facts of the illness 2. The social contexts of
occurrence of the illness 3. Meanings attributed to the illness by the patient 4. Opinions of family,
friends, and community about the illness II. Provide reasons for the ‘psychosis’ symptom is pathologic or
non-pathologic Elaborating explanations A. Biomedical (biological) Symptoms pattern and adaptive
functioning, use of prototypical case examples B. Normative response Cultural identity and illness
attributions C. Response to contextual factors Social stressors and available social supports D.
Misinterpretation Elements of patient-clinician (or other, e.g., refugee board) interaction III. Make a
diagnosis (use of prototypical case examples) Confirm psychosis Suggestive symptom pattern Response
to antipsychotic medication Poor engagement with help agencies Re-interpret as non-psychosis
Prominence of social vulnerability factors Presentation with prominent cultural or bodily idioms 26 Cult
Med Psychiatry (2015) 39:16–42 123 In problematization of meanings and attributions of the illness, CCS
meeting participants seek to clarify possible links between illness presentation, elicited meanings, and
events in the patient’s past or life, i.e., they seek to clarify the narrative function of the illness. This can
be seen in the excerpt below, of a middleaged woman and her mother, who had repeated conflicts and
litigation with their neighbors, diagnosed with folie a` deux: CCS Psychiatrist:… the neighbors she called
lesbians because they live together, you know as women and assume are practicing lesbians… this is
how she would talk about them in denigrating tones… and the police officer is a man who is corrupt and
is involved in sort of this whole scandal… so this is how she would talk about the improper people
around her Graduate Student: Did they come here following their expulsion by, uh… ? CCS Psychiatrist:
They came here because they felt that uh, control had reverted to Blacks in [her country of origin] and
they felt this was uh, an inferior kind of situation Culture Broker: [The country] was falling apart because
the Africans took over Graduate Student: This is sort of a situation of certain cultures that exist within
others that are very closed, and they seem to have brought some of that along with them [to Canada]
CCS Psychiatrist: We kind of got the feeling they were creating a little [version of her country of origin]
here In problematization of the views of patient’s family and community about the illness, the aim is to
clarify if people in patient’s social network ascribe pathology to the patient’s behavior. The excerpt
below, of a woman, refugee from a West African country, who had been avoiding social contacts,
demonstrates this effort to determine the response of others’ to the patient as an index of possible
presence of psychopathology in the patient: Caseworker: she (patient) has a sense of herself as being
normal and that… it shows more that she is not normal when she’s with them [members of the
community from her country of origin in Montreal].. . Culture Broker: They say that she is sad
Caseworker: Other people have actually said to us… other clients of ours who know her, have actually
said there is something really wrong with that girl, so I mean, her otherness is different CCS Psychiatrist:
It is interesting. So that evidence is diluted in the context of a more diverse population? Caseworker:
That’s right… that’s right The word ‘otherness’ used in the dialog by the caseworker suggests awareness
that in assessing a patient’s psychopathology attention needs be paid to differences arising from such
factors as patients ethnicity, refugee status, and that in teasing apart these different contributions to
patients psychopathology family and community members are of help in this regard. Cult Med
Psychiatry (2015) 39:16–42 27 123 Elaborating Explanations Once meeting participants have a grip on
the key diagnostic issues and uncertainties of the case, the focus shifts from problematization to
elaborating explanations aimed at providing reasons why the (apparent) psychotic symptoms are
pathological or non-pathological. In elaborating explanations, use is made of a reasoning process rooted
in any of four types of explanations: (i) biomedical causation; (ii) normative response; (iii) response to
contextual factors; and (iv) misinterpretation. In biomedical causation, considerations of (a) symptom
patterns and symptom persistence, (b) severity of symptoms, and (c) response to antipsychotic
medication, are used as explanations. The excerpt used here is of a woman with hallucinations and
paranoia who had fled to Canada to escape persecution after disclosure of her homosexuality: CCS
Psychiatrist: Diagnostically, the interesting issue is what to make of the hallucinations and the paranoia
Resident: Yeah, I struggled with that CCS Psychiatrist: Usually we see hallucinations either as totally
benign because they’re minimal, you know, you hear your name called, or we’re in a whole other
ballpark, and I think this kind of person who’s had a very severe trauma, who’s then having these
hallucinations is a difficult thing for us. Is this that she is having a psychotic process and it’s, you know,
related to what’s going on, or is it dissociative, as you said… Generally what I do is look for other signs of
thought disorder because that’s going to be the real deciding factor and if it’s just this kind of symptom
then try to use the smallest amount of neuroleptic possible and, if you can, use cognitive strategies In
normative response reasoning, the symptom/behavior is framed as culturally normative rather than an
indication of pathology, and mention is made of cultural identity and cultural illness explanations and
cultural idioms. This is seen in the excerpt below of a new mother with a history of epilepsy, who
presented with social withdrawal and selective mutism and was facing threats by social services to
remove her child because of concerns about her ability to care for the infant: Culture Broker: I wrote
about the idea of nesting in an African context…You know, to buy things for the baby and so forth, (that
it) would be seen as really you’re asking for trouble, you know…So it’s probably going against their
nature to some extent to start doing that. Also in her case, things like (the need for a) car seat she
probably doesn’t grasp at all, especially (since) she doesn’t have a car I’m sure, so that all these things
become irrelevant to her. CCS Psychiatrist: Why do you think, though, that it would be bad to prepare
too much… is there a supernatural explanation? Culture Broker: Yeah… it’s like… in an African context
you would never say about a baby… ‘‘oh, what a fat baby!’’ It’s a bit like the Mediterranean, ‘Evil Eye’…
you know, when you’re sort of commenting about good things about a baby, then you’re just attracting
that might be jealous… that will put a bad omen on the baby and the baby will get sick and lose weight,
and so forth 28 Cult Med Psychiatry (2015) 39:16–42 123 and so on, so that before the baby comes, you
don’t want to speculate. You’re kind of speculating on the baby by buying things and creating a context,
you are sort of assuming the baby will be there, and it’s not right to do that. That’s more or less the
reason… besides the fact that she’s still very religious, so that it’s God decision to decide whether the
baby is going to be there in good health, and so forth and so on. She has nothing to do with that, so she
has no right to start buying things or getting things done for the baby because she’s kind of stepping
over God’s will by doing that. And on the other side by sort of making a public show of the fact that
she’s gonna have a baby she’s attracting bad luck. Often women when they’re big like this and we say,
‘‘oh, when are you due?’’ they will look at you and ‘‘due what?’’ They won’t even say I’m pregnant. CCS
Psychiatrist: It jinxes Culture Broker: Because it will bring them bad luck In explanation by response to
contextual factors, the reasoning process links patient’s behavior to factors in the social environment,
stressors and absence of social supports. This is illustrated by the excerpt below, of a pregnant woman
admitted to the hospital with catatonia, who was being disruptive over the issue of access to the phone
while in the psychiatric ward: Referring Clinician :… things, family, friends, her environment is collapsing,
it cannot support her… and then there are some things coming out, like what she’s invested in the
telephone call, the money,… she was alluding, but not wanting to explain… it was one or two friends,
one friend, do you remember? Where she didn’t want to speak again with the sister, with the mother,
but it was a friend that she called, not recently, but who was dead… that could provide a link… that
something could be done. CCS Psychiatrist: That’s what she was saying. She was going to call her friends
in [patient’s country of origin] Referring Clinician: Maybe investing this person with this kind of magical
power… if I could only speak to this person, everything could be resolved. So everything became
invested in this telephone card, because if I don’t get it.. . CCS Psychiatrist: There is nothing, so she
became desperate In misinterpretation, the reasoning process frames the symptom/behavior as due to
miscommunications that arise in the patient-clinician encounter, as in this excerpt of a young male
immigrant from a country in the horn of Africa, referred because of social withdrawal, lack of
motivation, and treatment non-compliance: Culture Broker: When I saw him the impression that I had is
that he is very slow, he is forgetful, that’s what he said. Those kinds of things gave him the impression
that he does not like the medication Post-doc: The interesting thing (is) because he is a person who
doesn’t take initiative, it would be difficult for him to explain this and monitor himself. Culture Broker:
And because of the respect he has for his medical doctor, he will never say ‘‘I don’t like this.’’ If you
remember, when he came in the office, the guy when he came in and when he leaves he never turns his
back Cult Med Psychiatry (2015) 39:16–42 29 123 because of the tradition in [patient’s country of
origin]. When he arrived and he was going to close the door, he takes care to turn, but yet keeps eye
contact with you before he closes the door. If you don’t know it, you have the impression that he’s not
well oriented, but it’s cultural background. Previous research has commented on how clinician focus on
the ‘metaphor of compliance’ can lead to problems in patient-clinician communication and how
etiquette, a desire to be a ‘‘good patient’’ and cultural attitudes toward authority may lead patients to
maintain the (false) appearance of compliance with treatment in an effort not to offend the clinician
(Kirmayer, 2001). The next excerpt also illustrates the reasoning process rooted in misinterpretation.
Here, CCS case conference participants point out flawed inferences that were made about the patient’s
behavior due to differences in status between patient and clinician, the clinician’s lack of familiarity with
the patient’s background, and possible language barriers. The patient is a 38-year-old female refugee,
referred by her family doctor for social withdrawal and negativity and because he found her difficult to
assess: Referring Clinician (Family Doctor): I don’t have much information like you do. I’ve met with her
a few times. I think looking back and also listening to what you’re saying, what I see is that I was never
able really to make a good connection with her as she had some kind of very thankful attitude toward
me. And I think maybe because I had given her medication, her headaches were better and so on, but I
was never able to structure a follow-up where I wanted to send her for neurology consultation. Also, it’s
been a long time we’ve spoken about bringing her to see you and that never happened because she
doesn’t come for her appointment. Refugee Board Designated Representative: She disappears on us
from time to time. Referring Clinician (Family Doctor): So there’s no ability to continue. So I think that’s
why I couldn’t give you more information at the time. Also, things go slowly with her and it’s been quite
a long time now. I’m very happy that finally we were able to do this. CCS Psychiatrist: Finally getting
most of the information available out. Referring Clinician (Family Doctor): It’s difficult to get a working
relationship with her because probably she’s very defiant. Refugee Board Designated Representative: All
the information that I managed to gather is not through her: some is through her husband; some is
through a member of the community. So it’s just kind of a mosaic that I put together to get her profile.
But when you work with her, it is true that it is extremely difficult. Re-interpret Illness as Non-Psychotic
or Confirm Psychosis In the 11 cases where patient’s illness was re-interpreted as non-psychotic, more
weight was given in diagnostic decision-making to normative, contextual, and 30 Cult Med Psychiatry
(2015) 39:16–42 123 misinterpretation explanations, and less weight given to biomedical explanations,
as in this patient with paranoia and auditory hallucinations: CCS Psychiatrist: We have to end. Thank you
for your insights […] I think he’s really highly vulnerable. He is living a marginal life that could worsen if
he is refused [his claim for refugee status] by Canada. He has a mental illness. I am going to call it
depression. I am not sure he has psychotic features… he is lost, he is isolated. I think he has a very poor
prognosis. […] So I’ll draw attention to the [somatic] head symptoms. That’s kind of a marker in West
Africa. I don’t want to make stereotypes again, but that’s sort of an indication of depressive illness often.
In the 12 cases in which psychosis was confirmed, more weight was given to biomedical explanations in
diagnostic reasoning, less to contextual explanations, as in this man with catatonia, negative symptoms,
and auditory hallucinations: CCS Psychiatrist: We’ve had cases of people who have connections to dead
relatives in a more comforting way. I don’t think it’s the case for him though. I think it was more sort of
having these images, these horrific images. Culture Broker: What makes it seem likely to you that this is
a psychotic disorder (and not PTSD)? CCS Psychiatrist: It’s more from what I saw, from the history, the
admission, the odd and bizarre [behavior], his inappropriate affect, his giggling, hallucinations, delusions
which were described, and the fact that he is a lot better now taking his antipsychotic medication. I will
go with some kind of psychotic process and keep the PTSD in there so they [the referring team] don’t
forget about it The Use of Prototypes in Clinicians’ Reasoning Prototypes and exemplar cases featured
prominently in clinicians’ reasoning and were especially salient in (i) determining whether biomedical
causation explanations were sufficient and if a role existed for contextual explanations, and (ii)
confirming psychosis or re-interpreting as non-psychotic. In this context, prototypes are abstract
representations of typical patients in the clinician’s memory, while exemplars are instance-based
representations, i.e., actual images or accounts of previously seen patients. The excerpts used are from
the discussion of the case of a woman with hallucinations and paranoia who had fled to Canada after
disclosure of her homosexuality. The CCS psychiatrist invokes an example taken from his recent clinical
experience (i.e., an exemplar case): CCS Psychiatrist 1: I was called to see this woman in the emergency
room yesterday who when people open their cell phones on the Metro [subway] she’s convinced that
the screens send messages about her. So I mean this is fairly out there, right? But she said, ‘‘I know that I
need help… I mean this is crazy.’’ So she has a high level of insight, but a very psychotic symptom, you
know? Again it is a diagnostic conundrum, but veering toward thinking this is Cult Med Psychiatry (2015)
39:16–42 31 123 more like a schizophrenic thought process that’s going on for her than (what) you’ve
described for this lady [i.e., the CCS patient under discussion] Prototypical and exemplar cases served as
templates to which the patient’s presentation could be compared and provided ways to consider
potential contextual explanations: Post-doc: But doesn’t the randomness of the ideation make a
difference? I mean the cell phone one, I don’t know her background story, but that seems pretty
random, whereas this (CCS case) doesn’t CCS Psychiatrist 1: Absolutely. I think if there is a clear pattern
and it’s generalizing in a way that you would expect these things to generalize… that in effect is not a
paranoid disorder, it is a generalization of anxiety. Resident: What I struggled with is a lot of the
psychotic stuff was like cued by understandable things, like when she sees somebody African in the
street then she would get really, really paranoid. So it’s kind of like, uh, cueing anxiety CCS Psychiatrist 2:
I think it’s PTSD. CCS Psychiatrist 1: She’s hyper-vigilant… see I’m not sure she has a real delusion. She’s
tensely anxious, she’s misinterpreting things, she is over generalizing things, I mean all those things fit
within the domain of PTSD and anxiety. The next excerpt illustrates the use of a prototype in
determining whether biomedical causal explanations were sufficient, and if a role existed for contextual
explanations. The patient is a 37-year-old man, with a doctorate in engineering, diagnosed with
schizophrenia, and experiencing persistent auditory hallucinations: Post-doctoral fellow: It is very rare to
see someone develop schizophrenia after getting a PhD. The usual biological story for schizophrenia is a
gradual decompensation… from childhood actually. And the first thing that goes is cognitive functioning
rather than… Referring Clinician 1: He is a severely cognitively impaired adult. We see that he cannot…
this man has difficulty functioning, doing very simple tasks. And I have asked his friend, because his
friend is an engineer as well and they study together. And he [the friend] says that he [patient] is able to,
(but) not as before, but they are still able to go under conversation about engineering and some of the
stuff but sometimes no, sometimes he[patient] keeps talking, and then he just stops. But the friend says
that once in a while, he [patient] is still able… I don’t think he is able to think as before, but I don’t know
Referring Clinician 2: He can’t problem solve as before… Referring clinician 1: So for instance at [name of
community kitchen where patient does volunteer work] he became paralyzed, didn’t know how much
potatoes he is supposed to put on a plate. So he can put a piece of bread on a plate; he is fine because
he knows he could put one on the other plate. But the potato, he has to regulate the portion. He
couldn’t figure out the portion purposively. Post-doctoral fellow: Was he tested off medication for
cognitive function? Referring Clinician 1: This was off medication. 32 Cult Med Psychiatry (2015) 39:16–
42 123 At the start, the post-doctoral fellow (in psychology) points out how the patient differs from the
‘‘typical’’ or prototypical patient with schizophrenia. The referring clinicians and the CCS psychiatrist
counter with analytical reasoning, noting the adequacy of biomedical causal explanations given the
presence of cognitive impairment, response to antipsychotic medication, and poor level of functioning.
For added support, they reference more contextual normative explanations by citing the authority of
the patient’s friend as someone from the same African culture as the patient, who is also conversant
with patient’s social circumstances and pre-morbid functioning. Discussion In this study, we found that
in a multidisciplinary mental health team setting, the process of cultural formulation allowed for
emergence of a reflective, analytic, three-step reasoning process in resolving uncertainty of psychotic
disorder diagnosis, and that the use of prototypes and exemplars was key in clinicians’ reasoning and
diagnostic decision-making. The use of a three-step, rule-governed reasoning process in the CCS aligns
with research in clinical decision-making that suggest that under conditions of diagnostic ambiguity,
analytical reasoning displaces heuristics as the primary mode of reasoning (Mamede et al. 2007, 2012).
Reflective reasoning is cued when physicians are confronted with an ambiguous case, defined as ‘‘a
patient presentation that corresponds to the typical pattern of a disease but also includes features
consistent with alternative diagnoses’’ (Mamede et al. 2007, p. 1186). When faced with a complex or
ambiguous case, reflective reasoning helps focus the clinician’s attention on atypical features of the case
and engage in closer scrutiny of individual signs and symptoms (Mamede and Schmidt 2004). The threestep reasoning process used at the CCS has close parallels to Dewey’s 5-stage process of reflective
thought (Table 3). Uncertainty due to an emerging difficulty in solving a problem, stage one in Dewey’s
scheme, forms the background to the CCS assessment since patients are referred because of uncertainty
about diagnosis, prognosis, treatment plan, or other aspects of clinical care. Definition of the difficulty
by thoroughly understanding the nature of the problem, step two in Dewey’s scheme, corresponds to
problematization, the first step in the CCS deliberations. Generating explanations (through inductive
reasoning) and elaborating their implications (using deductive thought), which are steps three and four
in Dewey’s scheme, correspond to elaborating explanations, step 2 in the CCS process. Finally, step five
in Dewey’s scheme, testing resulting hypotheses by overt or imaginative action, corresponds to the third
step in our scheme, confirm/reinterpret (Table 3). Our model also bears some resemblance to the
multidimensional 5-factor model of reflective practice described by Mamede and Schmidt (2004). The
dimensions of deliberate induction and deliberate deductions in the multidimensional model are
equivalent to elaborating explanations in our own model; the testing hypotheses dimension in the
multidimensional model resembles confirm/re-interpret in our model; while, openness toward
reflection and metaCult Med Psychiatry (2015) 39:16–42 33 123 reasoning on the multidimensional
model are similar to problematization in our model (see Fig. 1). However, while, Mamede et al. (2007)
note that their 5 dimensions ‘do not correspond to a technically based strategy to be used step-bystep
by doctors… and may overlap’ (p. 1304), the reasoning process used in the CCS appears to have three
clearly demarcated and sequential steps Use of prototypes and exemplar cases featured prominently in
the reasoning process of clinicians, and these were especially salient in decision-making: (i) in
determining whether biomedical causation explanations were sufficient, and if a role existed for
contextual explanations, and (ii) confirming psychosis or re-interpreting the diagnosis as non-psychotic
(step 3). However, prototypes were used in conjunction with analytical reasoning in the process of
decision-making. This is consistent with the dual theory of cognition (Kahneman et al. 1982), which
suggests that heuristic and analytic reasoning systems will often act in concert. According to the dual
theory, on occasions when the two systems work in concert, the heuristic system will provide fast,
frugal, and often correct conclusions (Pelaccia et al. 2011; De Neys 2006; Kahneman 2011). By asking
clinicians to attend closely to the patient’s own understanding of the illness in social context, the
process of cultural formulation allows for a constructive engagement with uncertainty. Implicitly, it
invites clinicians to reflect on their own assumptions and adopt a stance of open inquiry toward
alternative ways of understanding the clinical problem at hand. The CCS use of a culture broker to
collect information for case formulation and the process of case discussion in a multidisciplinary setting
to elaborate the assessment together allowed clinicians to engage in reflective practice in an
environment that was informative, supportive, and Table 3 Comparison of CCS model with Dewey’s 5stages and Mamede and Schmidt’s 5-factor multidimensional model of reflective thought Dewey’s 5
stages Multidimensional model CCS model Stage 1: state of doubt or uncertainty due to an emergent
difficulty in understanding an event or solving a problem Occurs prior to referral to CCS: background for
referral to CCS Stage 2: definition of the difficulty by thoroughly understanding its nature Factor 4:
attitude of openness to reflection Step 1: problematization Factor 5: meta-reasoning Stage 3:
development of a suggested explanation or possible solution for the problem through inductive
reasoning Factor 1: deliberate induction Step 2: elaborating explanations Stage 4: rational elaboration of
the ideas produced through abstract, deductive thought focusing on their implications Factor 2:
deliberate deduction Stage 5: testing the resulting hypotheses by overt or imaginative action Factor 3:
testing generated hypotheses against problem at hand Step 3: confirm or re-interpret diagnosis 34 Cult
Med Psychiatry (2015) 39:16–42 123 non-threatening (Dinh et al. 2012). By guiding clinicians in
undertaking detailed evaluation of the social and cultural contexts of illness occurrence, the process of
cultural formulation enabled clinicians to appreciate the complexity of the case. The narrative
framework of the process of cultural formulation also allowed for a personfocused approach to case
evaluation, helping to draw attention the specifics of what may be atypical (ambiguous, troubling) about
a case (Mezzich et al. 2010). Our finding that prototypes and analytic reasoning were used in
conjunction in diagnostic decision-making has implications for understanding how errors might arise in
clinicians’ decision-making under conditions of uncertainty or ambiguity. According to the dual theory of
cognition, prepotent heuristics can bias reasoning in situations that require more elaborate, analytical
processing; that is, the two systems may conflict and cue different responses (De Neys 2006; Kahneman
2011). In such situations, the analytical system will need to override the heuristic reasoning system, if
conclusions are to be valid and error free. Typically, clinicians arrive at a diagnosis by ruling in a set of
symptoms as relevant and ruling out other symptoms as less relevant. This selectivity is a necessary
strategy in the clinic, but it is shaped by other factors that the clinician may be, unaware of, making
diagnosis prone to bias and error (Poland and Caplan 2004). Clinician bias in intercultural work may arise
from multiple factors including: (i) beliefs and attitudes about disadvantaged and ethnic minority groups
(e.g. the idea that some groups are more prone to psychoses); (ii) issues with empathy and countertransference, which exert unconscious influence or interfere with communication; (iii) lack of tolerance
of informational complexity or ambiguity which may lead the clinician to settle on a diagnosis too rapidly
before adequate information has been collected; and (iv) biases attributable to the clinician’s ‘cognitive
architecture’, that is processes of perception, attention and information processing, storage and recall,
and inference, for example, what sorts of information the clinician perceives, attends to or remembers,
and how the clinician uses available information (Poland and Caplan 2004). Clinicians may also be biased
by their disciplinary leanings and by practices specific to their professions, and by factors that are more
systemic and institutional in nature, such as resource constraints (Poland and Caplan 2004; Graber et al.
2002). As mentioned earlier, the process of cultural formulation prompted more complete and personfocused patient evaluations and encouraged clinicians to reflect on the quality of the interview and on
their own impact on the clinical encounter and this may have tended to reduce any impact of clinicians’
personal or professional biases on diagnostic assessment. The process of cultural formulation also
facilitated clinicians’ reflexivity and meta-reasoning, that is, the ‘‘ability to think about one’s own
thinking processes and to critically review one’s assumptions or beliefs regarding a problem’’ (Mamede
et al. 2007, p. 1304). This type of reflectiveness may reduce diagnostic errors that can arise from
clinician prejudice, judgment heuristics, or cognitive errors. Of course, the multidisciplinary team format
of the CCS meetings itself also likely facilitated openness and reflexivity, but without the demand for
attention created by the process of cultural formulation, the hierarchical professional relationships and
the dominance of the biomedical paradigm may limit the voice of non-psychiatrists in the team (Dinh et
al. 2012) Cult Med Psychiatry (2015) 39:16–42 35 123 The fact that use of prototypes figured
prominently in shaping diagnostic decisions, despite the emergence of reflexivity and wealth of new
information, suggests the potential importance of salient prototypes. Prototypes may be generated
through the clinician’s own clinical experience, training, or popular media representations and
stereotypes. Some investigators hold that clinician bias, leading to misdiagnosis, is rooted in prevalent
cultural stereotypes and prejudices about ethnic and racial minorities (e.g. White clinicians’ unconscious
tendency to view Black patients as violent and more disturbed, coincident with similar representations
of Blacks in majority culture) (Stone and Moskowitz 2011; Burgess et al. 2007; Lopez 1989; Abreu 1999).
Indeed, empirical research indicates that with repeated use stereotyping becomes implicit, invisible to
those who rely on it, even when an individual has training in diversity issues and makes conscious efforts
to avoid use of stereotypes (Stone and Moskowitz 2011). While the clinicians at the CCS case
conferences included in this study were alert to any representations of patients or their reference
groups in stereotypical language, such stereotyping still occurred, especially in the kinds of normative
explanations offered (e.g. witchcraft, evil eye, hex, in the case of African patients included in this study).
Often, this took the form of the use of language that essentialized culture and cultural difference, such
as stating that a patient’s behavior was attributable to his or her identity (e,g., as an African). However,
deciding that an explanation offered reflects a valid cultural norm and not a stereotype was often
difficult and open to debate. Finally, although we have focused primarily on cognitive processes, it is
possible that process of cultural formulation also facilitated the emergence of empathy in clinicians, and
that increased empathy in turn encouraged clinicians to engage in reflective reasoning (Kirmayer 2008).
Listening to the audio recordings of the CCS case conferences, one gets a sense from the affective tone
of the discussion that clinicians often had an empathetic stance toward patients. This is consistent with
a study by Dinh and colleagues (2012) who examined CCS transcripts for the styles of talk used by
meeting participants (including tone, style, and rhythm) as a way to gain access to the emotions of the
speakers and participants at the meeting. They documented many instances where referring clinicians
and other participants took positions of advocacy for the absent patient to challenge the medical
(psychiatric) prognosis of illness chronicity. Future work with a methodology like conversational analysis
might explore this affective dimension of the CCS case conferences more systematically. Conclusion In
this study, we sought to investigate the usefulness of the cultural formulation process in resolving
uncertainty of psychosis diagnosis in patients from immigrant and ethnic minority backgrounds seen at a
multidisciplinary cultural consultation service. Thematic analyses of CCS meeting transcripts of patients
who were immigrants from sub-Saharan Africa revealed use of a three-step reasoning process to resolve
uncertainty of psychotic disorder diagnosis. The process of cultural formulation with its attention to
culture and context in clinical assessments seemed 36 Cult Med Psychiatry (2015) 39:16–42 123 to
facilitate the emergence of a reflective, analytical reasoning approach to problem solving. However, the
research on judgment under conditions of diagnostic ambiguity or uncertainty, suggests that clinicians
would tend to resort to contemplative, more rule-based reasoning in any situation of great ambiguity, so
it remains unclear to what extent the process of cultural formulation itself was responsible for this
finding. We also found that the use of prototypical and exemplar cases drawn from experience in
intercultural work featured prominently in clinicians’ reasoning and seemed to play a crucial role in
diagnostic decisionmaking, in determining whether a psychotic disorder was present or absent. This
finding suggests that prototypes (and stereotypes) are important sources of clinician expertise and bias,
so that they need to be targeted specifically in cultural competence training. An example of such
competence training is described by Stone and Moskovitz (2011) who identified four strategies clinicians
could use when interacting with patients of a different ethnoracial background to reduce implicit bias: (i)
learn to associate such patients with egalitarian goals, (ii) seek common identities with the patient, (iii)
engage in counter-stereotyping, and (iv) take the perspective of the patient. Burgess et al. (2007)
described a similar set of evidencebased strategies to combat implicit bias among clinicians drawing
upon theory and research in cognitive social psychology. Furthermore, since CCS assessments take the
form of narratives that describe the patients’ experience and situate it in their life-world, the process of
cultural formulation appears to facilitate more thorough phenomenological evaluations, unlike the more
limited diagnostic assessments obtained with use of symptom checklists and structured diagnostic
interviews. As such, beyond allowing culture to be taken into consideration, the process of cultural
formulation may facilitate person-centered clinical assessment. Finally, our study adds to the growing
body of evidence on the usefulness of cultural consultation for developing strategies and tools for crosscultural evaluation that can facilitate clinician cultural competence (Kirmayer et al. 2003, 2008; Dinh et
al. 2012; Kirmayer et al. 2014). With increasing global migration and population diversity in most of the
developed world, ethno-specific approaches to mental health service delivery may need to be replaced
by service models that are more flexible, such as cultural consultation (Kirmayer et al. 2014).
Recognition of such diversity issues has led to increased calls for clinician training in cultural competence
(Betancourt 2004; Bhui et al. 2007). The study has important limitations. It examined a clinical sample
referred to a single specialized service, and this may have introduced unknown biases. The study
involved analysis of data collected primarily for clinical purposes, and in some instances the absence of
data may reflect inconsistencies in data recording rather than true differences between cases. There is
no ‘‘gold standard’’ in cross-cultural assessments, so CCS diagnoses are not necessarily more accurate
than those made by referring clinicians, a point that may apply especially to the general concept of
‘misinterpretation’ integral to our study premise. However, it seems reasonable that the more intensive
data collection and multidisciplinary reassessment of the CCS result in a more comprehensive picture of
the patients’ problems and predicament. The study had a relatively small sample size and focused
exclusively on patients Cult Med Psychiatry (2015) 39:16–42 37 123 who were immigrants from subSaharan Africa. There is a need to replicate this study with patients from other ethnic and cultural
backgrounds to see if the reasoning process observed in our analysis holds for other immigrant and
ethnic minority groups as well. Since patients do not participate in the CCS conferences, it is difficult to
comment on how they view the CCS formulation. However, an ongoing evaluation of the CCS suggests
that patients and clinicians find the process useful despite the challenge of meeting new consultants
outside their useful care setting. Although our findings suggest the clinical utility of the process of
cultural formulation for improving diagnostic accuracy, the precise aspects of the cultural consultation
process that contribute to this positive outcome are unknown. Research is needed to examine the
impact of various potential biases (heuristics, prototypes, cognitive errors) at different levels of the
evaluation process, from the level of the referring clinician to the CCS evaluation. Studies of the process
of clinical assessment and reasoning can contribute to efforts to refine the cultural formulation and
reduce bias in intercultural work. Lastly, our results provide further justification for the recent
introduction of an expanded version of the cultural formulation outline and a corresponding CFI in DSM5. Future work is needed to compare the use of the CFI with other methods of cultural formulation and
its impact in assessment, treatment adherence, and clinical outcomes. Conflict of interest The authors
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March 29, 2012
SAMHSA’s Working Definition of Recovery Updated
In December 2011, SAMHSA released a working definition of recovery and a set of
guiding principles.
The December release of this definition represented the
culmination of a lengthy process that began with an August 2010 Dialogue Meeting
and ended with a formal public engagement process (via the SAMHSA Feedback
Forum) in August 2011. At the time SAMHSA released the working definition, we
indicated that we would continue dialogue with the field to refine the definition and
principles. Based on additional stakeholder input, SAMHSA is now issuing a slightly
revised working definition and principles.
The revised working definition and principles give more emphasis to the role of
abstinence in recovery from addictions, and indicate that an individual may be in
recovery from a mental disorder, a substance use disorder, or both. The revised
definition is below.
SAMHSA appreciates the many thoughtful comments and suggestions received
SAMHSA will disseminate the working definition and principles as a
consumers, peers, family members, advocates, and others.
The definition and
principles are intended to help with the design, measurement, and reimbursement of
services and supports to meet the individualized needs of those with mental disorders
and substance use disorders.
Paolo del Vecchio
Acting Lead Recovery Support Strategic Initiative
Acting Director Center for Mental Health Services SAMHSA
SAMHSA’s Working Definition of Recovery from Mental Disorders and/or
Substance Use Disorders
The Substance Abuse and Mental Health Services (SAMHSA) recognizes there are
many different pathways to recovery and each individual determines his or her own
way. SAMHSA engaged in a dialogue with consumers, persons in recovery, family
members, advocates, policy-makers, administrators, providers, and others to develop
the following definition and guiding principles for recovery. The urgency of health
reform compels SAMHSA to define recovery and to promote the availability, quality,
and financing of vital services and supports that facilitate recovery for individuals. In
addition, the integration mandate in title II of the Americans with Disabilities Act and
the Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581 (1999) provide legal
requirements that are consistent with SAMHSA’s mission to promote a high-quality
and satisfying life in the community for all Americans.
Recovery from Mental Disorders and/or Substance Use Disorders: A process
of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential.
Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major
dimensions that support a life in recovery:
Health: overcoming or managing one’s disease(s) or symptoms-for example,
abstaining from use of alcohol, illicit drugs, and non-prescribed medications if
one has an addiction problem-and for everyone in recovery, making informed,
healthy choices that support physical and emotional wellbeing.
Home: a stable and safe place to live;
Purpose: meaningful daily activities, such as a job, school, volunteerism,
family caretaking, or creative endeavors, and the independence, income and
resources to participate in society; and
Community: relationships and social networks that provide support,
friendship, love, and hope.
Guiding Principles of Recovery
Recovery emerges from hope: The belief that recovery is real provides the
essential and motivating message of a better future – that people can and do
overcome the internal and external challenges, barriers, and obstacles that confront
them. Hope is internalized and can be fostered by peers, families, providers, allies,
and others. Hope is the catalyst of the recovery process.
person-driven: Self-determination
foundations for recovery as individuals define their own life goals and design their
unique path(s) towards those goals.
Individuals optimize their autonomy and
independence to the greatest extent possible by leading, controlling, and exercising
choice over the services and supports that assist their recovery and resilience. In so
doing, they are empowered and provided the resources to make informed decisions,
initiate recovery, build on their strengths, and gain or regain control over their lives.
Recovery occurs via many pathways: Individuals are unique with distinct needs,
experiences, that affect and determine their pathway(s) to recovery. Recovery is built
on the multiple capacities, strengths, talents, coping abilities, resources, and inherent
value of each individual. Recovery pathways are highly personalized. They may
include professional clinical treatment; use of medications; support from families and
in schools; faith-based approaches; peer support; and other approaches. Recovery
is non-linear, characterized by continual growth and improved functioning that may
involve setbacks. Because setbacks are a natural, though not inevitable, part of the
recovery process, it is essential to foster resilience for all individuals and families.
Abstinence from the use of alcohol, illicit drugs, and non-prescribed medications is
the goal for those with addictions. Use of tobacco and non-prescribed or illicit drugs
is not safe for anyone. In some cases, recovery pathways can be enabled by creating
a supportive environment. This is especially true for children, who may not have the
legal or developmental capacity to set their own course.
Recovery is holistic: Recovery encompasses an individual’s whole life, including
mind, body, spirit, and community. This includes addressing: self-care practices,
family, housing, employment, education, clinical treatment for mental disorders and
substance use disorders, services and supports, primary healthcare, dental care,
complementary and alternative services, faith, spirituality, creativity, social networks,
transportation, and community participation.
The array of services and supports
available should be integrated and coordinated.
Recovery is supported by peers and allies:
Mutual support and mutual aid
groups, including the sharing of experiential knowledge and skills, as well as social
learning, play an invaluable role in recovery. Peers encourage and engage other
peers and provide each other with a vital sense of belonging, supportive relationships,
valued roles, and community.
Through helping others and giving back to the
community, one helps one’s self.
Peer-operated supports and services provide
important resources to assist people along their journeys of recovery and
wellness. Professionals can also play an important role in the recovery process by
providing clinical treatment and other services that support individuals in their chosen
recovery paths. While peers and allies play an important role for many in recovery,
their role for children and youth may be slightly different. Peer supports for families
are very important for children with behavioral health problems and can also play a
supportive role for youth in recovery.
Recovery is supported through relationship and social networks:
important factor in the recovery process is the presence and involvement of people
who believe in the person’s ability to recover; who offer hope, support, and
encouragement; and who also suggest strategies and resources for change. Family
members, peers, providers, faith groups, community members, and other allies form
vital support networks. Through these relationships, people leave unhealthy and/or
unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend,
student, employee) that lead to a greater sense of belonging, personhood,
empowerment, autonomy, social inclusion, and community participation.
Recovery is culturally-based and influenced: Culture and cultural background in
all of its diverse representations, including values, traditions, and beliefs, are keys in
determining a person’s journey and unique pathway to recovery. Services should be
culturally grounded, attuned, sensitive, congruent, and competent, as well as
personalized to meet each individual’s unique needs.
Recovery is supported by addressing trauma: The experience of trauma (such
as physical or sexual abuse, domestic violence, war, disaster, and others) is often a
precursor to or associated with alcohol and drug use, mental health problems, and
related issues. Services and supports should be trauma-informed to foster safety
(physical and emotional) and trust, as well as promote choice, empowerment, and
responsibility: Individuals, families, and communities have strengths and resources
that serve as a foundation for recovery. In addition, individuals have a personal
responsibility for their own self-care and journeys of recovery. Individuals should be
supported in speaking for themselves. Families and significant others have
responsibilities to support their loved ones, especially for children and youth in
recovery. Communities have responsibilities to provide opportunities and resources
to address discrimination and to foster social inclusion and recovery. Individuals in
recovery also have a social responsibility and should have the ability to join with peers
to speak collectively about their strengths, needs, wants, desires, and aspirations.
Recovery is based on respect: Community, systems, and societal acceptance and
appreciation for people affected by mental health and substance use problems including protecting their rights and eliminating discrimination – are crucial in
achieving recovery.
There is a need to acknowledge that taking steps towards
recovery may require great courage. Self-acceptance, developing a positive and
meaningful sense of identity, and regaining belief in one’s self are particularly
SAMHSA has developed this working definition of recovery to help policy makers,
providers, funders, peers/consumers, and others design, measure, and reimburse for
integrated and holistic services and supports to more effectively meet the
individualized needs of those served.
Many advances have been made to promote recovery concepts and practices. There
are a variety of effective models and practices that States, communities, providers,
and others can use to promote recovery. However, much work remains to ensure
that recovery-oriented behavioral health services and systems are adopted and
implemented in every state and community. Drawing on research, practice, and
personal experience of recovering individuals, within the context of health reform,
SAMHSA will lead efforts to advance the understanding of recovery and ensure that
vital recovery supports and services are available and accessible to all who need and
want them.
D EBA T E Open Access An Integrated Recovery-oriented Model (IRM) for mental health services:
evolution and challenges Barry G. Frost1,2, Srinivasan Tirupati3,4, Suzanne Johnston3 , Megan Turrell3 ,
Terry J. Lewin2,3,4*, Ketrina A. Sly2,3,4 and Agatha M. Conrad2,3,4 Abstract Background: Over past
decades, improvements in longer-term clinical and personal outcomes for individuals experiencing
serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be
possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear;
however, there are a broad range of potential recovery contexts and contributors, both nonprofessional and professional. Ongoing refinement of recovery-oriented models for mental health (MH)
services needs to be fostered. Discussion: This descriptive paper outlines a service-wide Integrated
Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health,
wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial
interventions (EBIs) within a service context that supports recovery as both a process and an outcome.
Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant
recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation
approaches and literature; our own clinical and service delivery experience; and implementation,
evaluation and review strategies. The model revolves around the person’s changing recovery needs,
focusing on underlying processes and the service frameworks to support and reinforce hope as a
primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR)
practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery,
self-agency and social inclusion. Core IRM components are detailed (remediation of functioning;
collaborative restoration of skills and competencies; and active community reconnection), together with
associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of
these goals requires ongoing collaboration with community organisations. Conclusions: Improved
outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an
opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and
developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies
within MH services needs to occur in tandem with wide-ranging service evaluation strategies. Keywords:
Evidence-based psychosocial interventions, Hope, Mental health services, Models, Recovery, Recoveryoriented, Rehabilitation, Serious mental illness * Correspondence: Terry.Lewin@hnehealth.nsw.gov.au 2
Centre for Brain and Mental Health Research, Hunter New England Mental Health and the University of
Newcastle, Callaghan, NSW 2308, Australia 3 Hunter New England Mental Health, Newcastle, NSW 2300,
Australia Full list of author information is available at the end of the article © The Author(s). 2017 Open
Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
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