Case study in cultural formulation Cultural formulation overview Cultural formulation is developed with reference to: 1. DSM-5 Cultural Formulation Interview 2. DSM-5TR CFI Supplementary Modules 3. Outline for Cultural Formulation (OCF) – A Quick Reference Guide, Queensland Transcultural Mental Health Centre Addiction & Mental Health Services Domains of cultural formulation2,3: 1. Cultural identity, including language and spirituality/religious/moral traditions 2. Cultural conceptualisation of distress/explanatory model for problem, level of functioning 3. Psychosocial stressors and cultural features of vulnerability and resilience, coping and help seeking, contextual factors relating to immigration/being a refugee 4. Cultural features of the relationship between the individual and the clinician 5. Overall cultural assessment In guiding management planning1,2: ● Cultural definition of problem ● Cultural perceptions of cause, context & support ○ Causes ○ Stressors & supports ○ Role of cultural identity ● Cultural factors affecting self-coping and past help seeking ○ Self-coping ○ Past help seeking ○ barriers ● Cultural factors affecting current help seeking ○ Preferences ○ clinician-patient relationship —------------------------------------------Brief case description X is a 40 year old part Niuean, part Maori female living with her husband and children, who has a background of schizoaffective disorder and PTSD, who presented today for a routine medication review. Of note, her PTSD is a result of sexual trauma perpetrated by members of her paternal extended family. —---------------------------------------------------------Domains of cultural formulation in relation to X ● Cultural identity, including spirituality/religious/moral traditions and language While not stated explicitly, X appears to identify with a mix of European and Niuean cultures, with little identification with Maori culture. This is evidenced by: - Lack of contact with her Maori maternal family; continuing contact with the Niuean paternal family, despite past history of sexual assaults by members of this side of the family - Strong faith in Christianity, more typical of Pacific Cultures than NZ Maori culture. - She spoke very fluent English, being NZ-born. Niuean and Maori language proficiency need to be clarified. ● Cultural conceptualisation of distress/explanatory model for problem, level of functioning Primarily ascribes to a Western biological model of mental illness and accepts the disease model of schizoaffective disorder and PTSD. She also explicitly expressed incredulity towards a Maori model of explanation of positive symptoms of psychosis, in relation to both herself in the past and her daughter currently. Her interpretation of her trauma and the influence of that on her current mental health in a cultural context should be explored further and can potentially be an effective psychotherapeutic intervention. ● Psychosocial stressors and cultural features of vulnerability and resilience, coping and help seeking, contextual factors relating to immigration/being a refugee It appears X’s relationships with both the Maori and Niuean sides of her family are complicated. She suffered significant, recurrent trauma by members of the paternal family, and still feels implicit discrimination from the family for having spoken out about it. She lost contact with her mother and that side of the family after her parents’ divorce would be helpful to elicit her view on this part of her heritage, and whether there is a sense of loss/grief. ● Cultural features of the relationship between the individual and the clinician Engaging with Western Medicine based practitioners rather than traditional healers or healing practices. Good adherence with western medications. Embracing the Interpretative/deliberative models of care provided by the writer and the MH team. Someone who ascribes to a more traditional Pacific model of the clinician-patient relationship may see the relationship as more paternalistic. ● Overall cultural assessment X is influenced by both NZ European and Niuean cultures - it is evident that she sees biomedical Western medicine, her Christian belief and her nuclear family and possibly the Niuean extended family all as aspects that help her towards mental wellbeing. Her understanding of traditional Niuean cultural beliefs and practices toward sexual assaults, in particular by family members, and how these influenced those family members’ actions, should be clarified - this may help her to come to a sense of meaning and resolution in relation to her traumatic experiences. —-----------------Cultural formulation with respect to: ● Cultural definition of problem At the schizoaffective disorder/symptoms level, a Western biopsychosocial model appears most useful. It can help to explain the connection of her schizoaffective disorder with her trauma history, in conjunction with other risk factors. PTSD in relation to past sexual trauma - need to explore cultural interpretations both from X’s point of view and her family’s point of view (perpetrators or otherwise), and the family unit as a whole (incl X) would likely benefit from engage with professionals and/or significant community leaders to effect a sense of closure and resolution. ● Cultural perceptions of cause, context & support, and role of cultural identity X appears to have some insight into how her past trauma is affecting her MH currently, although the link can be explored further and made more explicit through education. Her own nuclear family and religious faith are central to her current coping style. Husband appears to be her main support person - need to clarify his cultural identity as a key member of social network.. Despite the history of trauma, she is not disavowing the Niuean aspect of her identity and continues to engage with her Niuean family. Need to clarify whether these relationships are currently beneficial or detrimental to her mental state, and in what contexts. Notes suggest she sees her father positively. ● Cultural factors affecting self-coping, past help seeking, and barriers For schizoaffective symptoms: western biological medications + faith based self-coping + social support from family have all proven to be beneficial for her mental health, although she remains prone to symptom relapse. For PTSD related to sexual trauma: while trauma-focused CBT & EMDR in a Western medical context are likely to be helpful, there may also be benefits towards mental healing in engaging with relevant family members through culturally-sanctioned individuals or institutions, e.g. church pastor/elder, respected members of the Niuean community; possibly her father, being the ‘elder’ of the family (Pacific cultures respect older people’s wisdom). ● Cultural factors affecting current help seeking - preferences & clinician-patient relationship As X evidently is well-versed in and accepts NZ European culture, there are no significant concerns with her engagement with mainstream MHS. Provided faith-based practices are not in contradiction with mainstream treatments, these can be encouraged, as it is evident that her religious faith is very important to her sense of identity and self-worth, as well being an avenue to relieve mental distress through praying.
