Abstract
The patient–therapist relationship is crucial for the outcome of psychotherapy. This has been shown in research, and it is also a common opinion among psychotherapists. Nowadays, the relationship is not only seen as a process of transference and countertransference, but also in terms of bonding, setting goals and defining tasks.
Intercultural psychotherapy has its own difficulties, since patients and therapists differ more in these processes. Also, there are commonly quite different idioms of distress. A more thorough phase of determining the relationship is necessary, with stages in which both patients as therapists define their role. In different cultures there are quite different perceptions of their role and identity, which can result in misunderstanding and absence of treatment effect.
In order to overcome these difficulties, a proposal is to use the Cultural Formulation Interview (CFI), an interview designed for situations in which there is a great gap between the culture of the patient and of the therapist. Next to this core CFI there is a supplementary module, the Patient–Clinician Relationship Module, which can enlarge the relationship because in this interview most of the delicate questions are asked for.
To write prescriptions is easy, but to relate to people in other ways is difficult.—Franz Kafka (1919): A country doctor.
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Notes
- 1.
Cultural identity of the individual: describes the individual’s racial, ethnic, or cultural reference groups that may influence his or her relationships with others, access to sources, and developmental and current challenges, conflicts, or predicaments. For immigrants and racial or ethnic communities, the degree and kinds of involvement with both the culture of origin and the host culture should be noted separately. Language abilities, preferences, and patterns of use are relevant for identifying difficulties with access to care, social integration, and the need for an interpreter. Other clinically relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual orientation ([38], pp. 749–750).
- 2.
Cultural conceptualisations of distress: describe the cultural constructs that influence how the individual experiences, understands, and communicates his or her symptoms or problems to others. These constructs may include cultural syndromes, idioms of distress, and explanatory models or perceived causes. The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups. Assessment of co** and help-seeking patterns should consider the use of professional as well as traditional, alternative, or complementary sources of care ([38], p. 750).
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Psychosocial stressors and cultural features of vulnerability and resilience: identify key stressors and supports in the individual’s social environment (which may include both local and distant events) and the role of religion, family, and other social networks (e.g. friends, neighbors, co-workers) in providing emotional, instrumental, and informational support. Social stressors and social support vary with cultural interpretation of events, family structure, developmental tasks, and social context. Levels of functioning, disability, and resilience should be assessed in light of individual’s cultural reference groups ([38], p. 750).
- 4.
Cultural features of the relationship between the individual and the clinician: identify differences in culture, language, and social status between an individual and clinician that may cause difficulties in communication and may influence diagnosis and treatment. Experiences of racism and discrimination in the larger society may impede establishing trust and safety in the clinical diagnostic encounter. Effects may include problems eliciting symptoms, misunderstanding of the cultural and clinical significance of symptoms and behaviors, and difficulty establishing or maintaining the rapport needed for an effective clinical alliance ([38], p. 750).
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Supplement (Freely Downloadable at https://www.psychiatry.org/)
Supplement (Freely Downloadable at https://www.psychiatry.org/)
Supplementary Module of the Cultural Formulation Interview
Patient–Clinician Relationship
Related Core CFI Question
16 Some of the core CFI questions are repeated below and are marked with an asterisk (∗). The CFI question that is repeated is indicated in brackets.
Guide to Interviewer
The following questions address the role of culture in the patient–clinician relationship with respect to the individual’s presenting concerns and to the clinician’s evaluation of the individual’s problem. We use the word culture broadly to refer to all the ways the individual understands his or her identity and experience in terms of groups, communities or other collectivities, including national or geographic origin, ethnic community, racialised categories, gender, sexual orientation, social class, religion/spirituality and language.
The first set of questions evaluates four domains in the clinician–patient relationship from the point of view of the patient: experiences, expectations, communication and possibility of collaboration with the clinician. The second set of questions is directed to the clinician to guide reflection on the role of cultural factors in the clinical relationship, the assessment and treatment planning.
Introduction for the Patient
I would like to learn about how it has been for you to talk with me and other clinicians about your [PROBLEM] and your health more generally. I will ask some questions about your views, concerns and expectations.
Questions for the Patient:
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What kind of experiences have you had with clinicians in the past? What was most helpful to you?
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Have you had difficulties with clinicians in the past? What did you find difficult or unhelpful?
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Now let’s talk about the help that you would like to get here. Some people prefer clinicians of a similar background (for example, age, race, religion or some other characteristic) because they think it may be easier to understand each other. Do you have any preference or ideas about what kind of clinician might understand you best?
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∗Sometimes differences among patients and clinicians make it difficult for them to understand each other. Do you have any concerns about this? If so, in what way? [RELATED TO CFI Q#16.]
Guide to Interviewer
Question #5 addresses the patient–clinician relationship moving forward in treatment. It elicits the patient’s expectations of the clinician and may be used to start a discussion on how the two of them can collaborate in the individual’s care.
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What patients expect from their clinicians is important. As we move forward in your care, how can we best work together?
Questions for the Clinician After the Interview:
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How did you feel about your relationship with the patient? Did cultural similarities and differences influence your relationship? In what way?
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What was the quality of communication with the patient? Did cultural similarities and differences influence your communication? In what way?
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If you used an interpreter, how did the presence of an interpreter or his/her way of interpreting influence your relationship or your communication with the patient and the information you received?
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How do the patient’s cultural background or identity, life situation, and/or social context influence your understanding of his/her problem and your diagnostic assessment?
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How do the patient’s cultural background or identity, life situation, and/or social context influence your treatment plan or recommendations?
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Did the clinical encounter confirm or call into question any of your prior ideas about the cultural background or identity of the patient? If so, in what way?
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Are there aspects of your own identity that may influence your attitudes toward this patient?
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Rohlof, H. (2020). The Patient–Therapist Relationship in Intercultural Psychotherapy. In: Schouler-Ocak, M., Kastrup, M. (eds) Intercultural Psychotherapy. Springer, Cham. https://doi.org/10.1007/978-3-030-24082-0_8
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