Adapting the Cultural Formulation for Clinical Assessments in Forensic Psychiatry
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* Neil Krishan Aggarwal

## Abstract

Even as forensic psychiatrists have increasingly contemplated the role of culture in forensic psychiatry, practical cultural evaluations remain an under-theorized area with scant research. Older conceptions of cultural competence may risk stereotyping the evaluee on the basis of perceived group characteristics. This article offers a revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) Outline for Cultural Formulation for use in forensic psychiatry by adjusting its formal guidelines with recommendations from the forensic mental health literature. As a person-centered method of conducting the interview, the Cultural Formulation probes cultural explanations of identity, illness, social support, functioning, and interaction with the medical and legal systems. In line with other psychiatric subspecialties, future research in forensic psychiatry can examine the extent to which the Cultural Formulation helps trainees with cultural competence, reconfigures diagnosis and treatment, and alters legal outcomes such as length of sentence.

Researchers have long pointed to the role of culture in legal medicine. The law is based on culturally determined values and styles of judicial reasoning.1,–,5 Culture grounds the professional ethics6,7 and the notion of boundaries8 among forensic psychiatrists. It patterns expressions of criminal behavior such as homicide-suicide in older adults9 and school shootings among adolescents.10 It influences the types of mental health services offered through the justice system11 and directly informs questions about capacity to distinguish between right and wrong conduct, the presence of criminal intent in punishable behavior, and expectations of retribution and rehabilitation.12 Invocations of insanity13 and mental incapacity based on personality disorders14 also vary across cultures. Cultural discrimination can produce traumatic stress in minority groups,15,16 who face disproportionate use of seclusion,17 restrictive hospital orders,18 and deficient clinical assessments19,20 in forensic facilities. Foreigners tend to commit suicide in prison after problems with acculturation,21 prompting debates over separate forensic services for ethnic minorities.22 Despite broad insights into culture's influence on the medicolegal system, culture in forensic evaluations remains poorly understood.

## Current Cultural Recommendations in Forensic Psychiatry

General techniques for forensic cultural evaluations have not received significant attention. Many textbooks omit cultural evaluations altogether.23,–,26 Some mention culture's influence on a single problem, such as refusal of treatment.27 Others refer to ethnic and racial disparities in the forensic system without attending to assessments.28,–,31 One landmark text exhaustively reviews the cultural dimensions of psychiatric disorders and criminal behaviors,32 but may not guide the reader in the actual interview.

Other well-intended authors list prescriptions and proscriptions for individual clients on the basis of group characteristics. For example, it is contended that the Asian family is ordered along patriarchal lines and that “the woman is not considered of any economic value even though she may work hard in the fields” (Ref. 33, p 177). The term Asian covers billions of people from North Africa and the Middle East to South, East, and Southeast Asia with thousands of languages and phenotypes; which Asians were analyzed here? Moreover, female prime ministers, of high economic value, have ruled India, Pakistan, and Bangladesh, defying this assertion. Another example supposes that “a Muslim woman has to wear, at all times, a full dress from the neck to the ankle and also completely cover her hair unless she is in the company of her husband or other close male relatives or other females” (Ref. 34, p 219). This statement may not account for cultural diversity within the Muslim world, differences among sects, and the secular outlook of many who prioritize other identities. There are similar suggestions that Filipinos disapprove of outsiders' questioning their families, Cambodians emphasize that men are always correct, and Australian aborigines refuse to say a person's name for six months after his death.35

Cross-cultural researchers have advised against group approaches to individual care. Cultures are dynamic throughout history.36 Information technology and globalization have allowed people to physically and psychologically travel and accumulate new influences.37 In addition, generalizations minimize internal differences and ignore how individuals select hybrid identities from multiple cultural references.38

Instead, psychiatrists have rethought culture for clinical purposes. The National Institute of Mental Health's (NIMH) Culture and Diagnosis Group has defined culture as “meanings, values and behavioral norms that are learned and transmitted in the dominant society and within its social groups. Culture powerfully influences cognition, feelings and self-concept as well as the diagnostic process and treatment decisions” (Ref. 39, p 118). Forensic psychiatrists must detect a client's values and behavioral norms that are relevant to the consultation. Therefore, the forensic psychiatrist, like the cultural psychiatrist, must situate the individual in his or her social world. A method of cultural evaluation in forensic psychiatry may aid in this enormous challenge. Otherwise, to begin cultural evaluations by presuming similarities in a perceived group demographic such as phenotype, geography, or religion may ironically risk stereotyping the client.

## The Cultural Formulation's Relevance to Forensic Psychiatry

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV)40 Outline for Cultural Formulation (hereinafter, Cultural Formulation) can equip forensic psychiatrists during consultation. Originating from an NIMH workgroup that offered recommendations for DSM-IV, the Cultural Formulation was published in 1994, envisioning the clinical encounter across four main domains: the patient's relationships to cultural identity, current illness experience, psychosocial supports and daily functioning, and the biomedical system (including the physician), with a fifth domain added when this information alters diagnosis and treatment.40 The formulation was designed for several functions such as allowing patients to articulate illness experiences, standardizing evaluations, and educating clinicians and researchers.41

The Cultural Formulation has since revolutionized cultural psychiatry. As an ethnographic method of eliciting explanatory models, it has produced patient-oriented narratives corresponding to the patient-centered movement in medicine.42 Field trials of the formulation among various ethnicities have validated its utility with helpful examples.43 Journals, such as *Culture*, *Medicine*, *and Psychiatry*44 and *Transcultural Psychiatry*,45 have standardized the formulation's format and published case studies demonstrating its effect on diagnosis and treatment. In addition, the Cultural Formulation is a benchmark for education and the evaluation of cultural competence in psychiatry.46,–,48

However, the Cultural Formulation has had little impact in forensic psychiatry. Several cases have demonstrated its helpfulness in forensic consultations,49,–,52 especially in reducing sentences,53 but these articles preceded the publication of formal guidelines for the Cultural Formulation. 54 Psychiatrists have progressively suggested that the Cultural Formulation2,55,56 and theories from cultural psychiatry8,57 could enrich forensic psychiatry. Many disparities result from systemic problems such as excessive incarceration of minorities and barriers to treatment,58 and a Cultural Formulation for forensic psychiatrists could further reduce disparities, especially given provider concerns about the lack of diversity training.59 The remainder of this article elaborates a formulation designed specifically for forensic psychiatry.

## A Cultural Formulation for Forensic Psychiatry

Since many consultations call for the appraisal of a client's relevant cultural standards, a Cultural Formulation for forensic psychiatry is of interest. Even though questions about competence to stand trial, testifying, making a will, consenting to medical treatment, and managing funds require less cross-cultural skill, since functional performance is emphasized over diagnosis, examinations for personal liability injury, competence to parent, child custody, special education, disability accommodation, employment disability, workplace injury, diminished capacity, mitigation/aggravation, and the insanity defense utilize culturally relative standards for evaluation.60 Formal guidelines for the Cultural Formulation11 based on sample questions have been amended with recommendations from the forensic mental health literature.

### The Cultural Identity of the Individual

Most mental health professionals identify the patient's ethnic or cultural reference group, often a linguistic, religious, or national affiliation. Nonetheless, people may prioritize identities from political viewpoints, sexual orientation, migration status, physical disability, or social standing (such as veterans groups or ex-convicts). Rather than make assumptions, forensic professionals can ask clients how they self-identify. (Where are you and your family from? What is your ancestry? Are there cultural differences between you and your parents? Do you feel a strong connection to any groups of people? If so, to whom?) This information can readily fit in the identifying data section of the forensic report. For immigrants and refugees, forensic psychiatrists can also detect acculturation in cultures of origin and resettlement. (What foods do you eat? What holidays do you celebrate? What television channels, radio stations, books, magazines, or Internet sites do you like? What values of your culture do you share or reject? How close do you feel to your community?)

Forensic psychiatrists face unique demands. Globalization has stimulated immigration and multiculturalism in North Atlantic countries, presenting psychiatrists with unprecedented difficulties in cultural and linguistic competence.61 Forensic professionals can ask clients about language preferences with family, friends, and health care professionals. Such considerations are not trivial, given that clients come with various abilities in oral and written literacy and that foreign clients may not possess equivalent linguistic or legal terms and concepts in their birth societies.62 (What languages do you speak? With whom and when? What language would you like to speak with me? Do you understand the legal terms and charges against you? Are there similar terms for them in your culture? What are they?) If necessary, forensic psychiatrists should call for court-certified interpreters who can be available for multiple interviews and translate sensitive content, slang, profanity, racial slurs, affect, and speech styles, noting untranslatable or unfamiliar words.63 Forensic psychiatrists would benefit from forming an alliance with the interpreter and recording logistics in the introduction to the report.

### Cultural Explanations of the Individual's Illness

The Cultural Formulation recommends that clinicians ask patients about illness beliefs. Forensic professionals can ask evaluees how they name and understand the cause, diagnosis, treatment, and prognosis of their illness. (Do you or anyone else have a name for the problem you're having now? Why do you think it is happening to you? What will make it better or worse? When did it start and when do you think it will get better?) A family history may elicit household experiences of illness and treatment, and whether these resemble the evaluee's presentation and understanding of illness. (Has anyone else you know ever had this problem? What activities has this problem stopped you from doing that you, your family, or your friends expect?) Furthermore, clinicians can inquire about help-seeking behavior. (Whom have you seen for help with this problem?) This information around culture and mental health could be recorded in the psychiatric and substance histories.

The forensic professional can analogously surmise the client's views on the legal system. The expert might discover cultural influences on the motivations behind punishable behaviors and the ability to distinguish between right and wrong. (Do you know anyone else who faced similar problems or situations? How did they handle the problem? How are such situations handled where you come from?) This information pertains to judgment and insight. Since judicial systems vary across cultures, cultural competence entails discovering the client's conceptions of punishment and rehabilitation, especially for immigrants and refugees. (Is there a term for this type of problem or behavior? Does the legal system get involved in these circumstances? Are people with these behaviors normally helped or punished? If so, how?) This information affects how the client perceives of the consultation.

### Cultural Factors Related to Psychosocial Environment and Levels of Functioning

The Cultural Formulation recommends identification of social supports, stressors, and impact of illness on daily living. Such evaluations directly relate to civil litigation such as workers' compensation and personal injury.53 The psychiatrist notes who constitutes the household and from whom the evaluee draws support during stress. (Who lives at home with you? Can they help with this problem? Who else can help you? Is anything going on to make this problem better or worse?) Family involvement in illness, legal services, court proceedings, and visitation during incarceration differs based on whether people live in individualistic or collective cultures.64 To discover levels of functioning and disability, professionals can discover expected roles, activities, and responsibilities affected by the incident and how the evaluee draws upon people or services for help. (How has this problem affected your life? Is it preventing you from working? From moving, grooming, feeding, or sleeping? Do people close to you understand how you feel?) Forensic professionals can also contact family members and friends within the bounds of privacy for cultural collateral information. This information could be encapsulated within the social history.

### Cultural Elements of the Patient-Physician Relationship

The Cultural Formulation openly recognizes that race, language, religion, class, and education shape a patient's relationship with the biomedical system. Forensic professionals can ask interviewees how they view physicians to detect stigma around mental illness and engagement with mental health practitioners. (Do your friends and family talk with doctors about problems like the one you have? Do you think your friends or family would be upset if you spoke to physicians about your problems? Do you have any wishes for or concerns about treatment? What are your thoughts about medications or psychotherapy?) This information would be critical for discussion as it addresses cultural attitudes regarding health and illness.

Forensic professionals could also use this opportunity to reflect on the consequences of their own cultural identities with evaluees, especially around values, language, communication, socioeconomic class, intercultural affinities and enmities, and observations regarding behavior and treatment. Unconscious biases in emotions, motivations, fund of knowledge, and information processing may prejudice the expert,65 as can ethnic, racial, and cultural biases against the evaluee,66 which an internal dialogue may limit. (Have I considered potential biases in the diagnosis of the evaluee? Have the psychological or risk assessment tests been validated for the evaluee's ethnic or linguistic group? Have I considered potential biases in assessing dangerousness?) Likewise, the forensic professional could introspect about the risks of cultural connectedness.67 (Am I overidentifying with this evaluee? Is the attorney retaining me on the basis of ethnocultural similarities with the client? Am I ignoring results from the medical or psychiatric examination? Is the evaluee disclosing too much based on perceptions of a shared background?) Ethnocultural transferences and countertransferences assume myriad forms and can change the clinical assessment.68 Attention to relatedness would illuminate the dynamics of the entire evaluation.

### Summary: Overall Cultural Assessment for Diagnosis and Care

By appraising the above areas, the forensic expert can better formulate a diagnosis and assessment that are sensitive and person-centered. Cultural findings from the examination could be checked against the social science and psychiatry literature to gauge the cultural determinants of an evaluee's symptom or behavior.69 This research literature can act as cultural collateral information, much as other collateral sources strengthen the forensic report.70 A measure of concordance with cultural collaterals can be listed in the report to demonstrate whether the evaluee is exaggerating cultural factors in presentation.

## Conclusions

This article has reviewed the role of culture in forensic psychiatry and advanced a method for systematic cultural evaluation. Older models of cultural competency frequently attribute behavior to an essentialized group demographic such as race, language, or ethnicity. In contrast, the Cultural Formulation makes no such presumption and invites the client to discuss experiences with identity, mental illness, social networks, and the medical and legal systems. Furthermore, cultural information can be practically included in standard sections of forensic reports.

Beyond clinical evaluation, the Cultural Formulation can be used for research. The outline here represents one possibility, but forensic psychiatrists may discern that this Cultural Formulation captures too much information in one domain and not enough in another for certain consultations. Implementation studies can establish whether the Cultural Formulation works for all or certain populations, requires specific conditions, and ultimately informs diagnosis and assessment as previous studies have shown.71,–,74 Outcome studies can also reveal whether the Cultural Formulation changed a case through claims, charges, or time sentenced. Such research can restore balance in the forensic literature in which the problems of patient pathologies typically outweigh the solutions offered to them regarding treatment and quality of life.75

Research on the Cultural Formulation also falls in line with recent forensic interest in narrative. Prominent researchers have questioned the forensic report as an impersonal and objective document by highlighting the author's social, cultural, financial, and legal positions, and the complexity in transforming information from disparate sources into a coherent, persuasive narrative with legal purpose.76,77 Such an enterprise is useful since reflection may clarify the evaluator's own multitudes of identities at play.78 The Cultural Formulation's explicit scrutiny of cultural variables calls the evaluator to this endeavor even as it may reduce health disparities within forensic psychiatry, a worthwhile project for future researchers.

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: Dr. Aggarwal is an unpaid consultant to the DSM-5 Gender and Cross-Cultural Study Group.

*   © 2012 American Academy of Psychiatry and the Law

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