Psychiatric and mental health in America has not succeeded at engaging people diagnosed with mental illness in their own care and empowering them and their families to become true partners with their providers.

Misunderstandings and miscommunications can lead to dissatisfaction with treatment and sometimes even discontinuation. But when thewholeof a person is taken into account, not only is the person likely to stay in treatment, they are likely to have a greater chance of recovery.

Take for instance this following example:

Zach was discharged two days ago after a three-week psychiatric hospitalization, with the hope that he can find a clinician he can trust. All he has for now are follow-up appointments with his hospital psychiatrist, and a new clinical psychologist. Zach is confused, vulnerable, and wonders if he could have done something to avoid this hospitalization.

Zach has not seen a mental health professional in years, but he is willing to try. He walks into Dr. P's office and says to him,

"Before we get started, I just want to tell you that I am gay. I grew up Jewish but I consider myself a Christian today. I haven't seen a shrink in a long time because I had a bad experience, and I need to know if talking about all of this is going to be OK with you."

Dr. P. does not miss a beat. He looks at Zach right in the eye and thanks him for being so open with him. He can see that Zach needs be heard right here and right now. So he decides to ask Zach if he could talk about what brings him here today and what is bothering him the most. Then, Dr. P. asks what he what sees is causing this, how other people in his life such as his family and friends see what is happening to him, and what his most important stressors and supports are. He tells Zach that he would like to get to know him and understand what his identities mean to him.

Dr. P. understands that in order to help Zach, he has to look beyond just Zach and take into account his cultural identity. Unknowingly Dr. P has followed the spirit of the Cultural Formulation Interview (CFI) published in the 2013Diagnostic and Statistical Manual of Mental Disorders, fifth edition(DSM-5). As a result, Zach can now not only breathe, but also talk about his views of himself, his values, and his expectations of therapy. His story has been finally heard.

On the surface, the CFI is a set of 16 questions to help clinicians have meaningful conversations with people diagnoses with mental illness about their cultural identities, the way they and others close to them see what is happening to them, what is causing it, prior experiences of care, and what type of help they would like. At a deeper level, the CFI is not just an interview tool, but an attempt to radically transform the therapeutic relationship and build a stronger partnership and therapeutic alliance between clinicians, people with mental illness and those who support them.

The goal of the CFI is to lay the foundation for person-centered care and shared decision-making by encouraging clinicians to engage people seeking services and their families, from the very start, in a dialogue about how their cultural identities, values and prior experiences shape their care expectations and goals. But the CFI remains an underdeveloped tool. Clinicians and people living with mental illness need to know that it exists, and to use it to build a new type of partnership, without prejudice or stereotypes. All people diagnosed with mental illness have cultural identities,and our mental health system cannot expect any one of them to leave who they are at the door.

By Oscar Jiménez-Solomon, M.P.H., Chacku Mathai, C.P.R.P., Neil Aggarwal, M.D., M.A., & Roberto Lewis-Fernández, M.D.

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