Patient Identity Narratives Through the Cultural Formulation Interview in a New York City Outpatient Clinic

Abstract

Anthropologists have critiqued cultural competence programs in medical settings while introducing mental health clinicians to social theories on culture for practice. We explore how patients articulated narratives about themselves and how clinicians responded to such narratives through an intervention known as the Cultural Formulation Interview that anthropologists have helped develop. We conducted over 500 hours of fieldwork from 2014 to 2019 at an outpatient clinic in New York, analyzing multiple data (participant observation, medical records, patient-clinician sessions, and individual debriefing interviews) in a trial joining clinical and ethnographic methods. Our study enrolled 45 patients and six clinicians, yielding 117 patient-clinician appointments and 98 debriefing interviews. Most patients differed in how they presented their identities through demographic forms and discussed them in sessions with their clinicians. Two-thirds of the patients drew connections between their personal identities and experiences of mental illness. These results reveal why cultural identities should not be taken for granted in clinical settings.

INTRODUCTION

Anthropologists have emphasized the complex, contested nature of identities as personal identifications and in cultural competence programs. Activists from minoritized ethnoracial communities lobbied for such programs through poverty alleviation campaigns in the post–civil rights era of the 1970s and 1980s, and then through race-based demands of minority workforce recruitment and patient-clinician ethnic matching in the 1990s (Shaw, 2005). Medical schools responded to the rise of multiculturalism in American education throughout the 1990s and assigned case studies that portrayed the cultures of unfamiliar patients as static and ethnoracially biased (Taylor, 2003). In the late 1990s, clinicians represented minoritized ethnoracial and immigrant patients as being at greater risk for illnesses based on acculturation challenges compared with white patients to receive increased funding for services (Santiago-Irizarry, 1996).

Ethnographic work shows mixed reactions to cultural competence interventions. Encouraging clinicians to explore dynamic conceptions of culture can confuse those without training in the social sciences and can lead to using race and ethnicity categories that perpetuate stereotypes (Aggarwal et al., 2013). Trainees have criticized race- and ethnicity-based courses for the underlying assumption that “mainstream” clinicians treat “Other” patients (Willen et al., 2010). Even faculty members who specialize in cultural competence and strive to create “safe spaces” to discuss unconscious biases may assume that participants exhibit biases from knowledge deficits, not from negative emotions (Hannah and Carpenter-Song, 2013). Cultural competence programs operationalize culture inconsistently, often as synonymous with race and ethnicity; as a problem solved through patient-clinician language matching; as reproduced through material objects such as crafts, films, books, and magazines; as commemorated through festivals; or, as lists of values and behaviors that clinicians should adopt with patients (Guarnaccia and Rodriguez, 1996).

Anthropologists have proposed that cultural competence programs adopt, instead, conceptions of culture from the social sciences. Some propose “a process-oriented approach” that emphasizes flexibility “to facilitate clinical encounters characterized by openness and a willingness to seek clarification” (Carpenter-Song, Schwallie, and Longhofer, 2007, 1364). Others recommend that clinicians complete a “mini ethnography” by asking patients about identity, its relevance to illness, what is at stake now, illness explanatory models, psychosocial stressors and supports, and cultural differences with clinicians (Kleinman and Benson, 2006). A third recommendation is to provide “safe spaces” for clinicians to voice insecurities when treating unfamiliar patients, a stance that conflicts with biomedicine’s emphasis on skills-based competence (Willen, 2013).

Since the 1970s, anthropologists have collaborated with psychiatrists to improve care for patients while scrutinizing psychiatric knowledge and practice as historically constructed (Kirmayer, 2007). This article answers two research questions: (1) How do patients respond to clinicians’ questions on cultural identities? and (2) How do patients relate their identities to experiences with mental illness? Through clinical ethnography, we analyze patient-clinician encounters to show how patients self-identify and connect these identifications to mental illness when clinicians ask open-ended questions through the Cultural Formulation Interview (CFI) (APA, 2013a), a widespread initiative in mental health settings to which anthropologists have contributed for more than three decades.

ANTHROPOLOGICAL CONTRIBUTIONS TO CULTURAL ASSESSMENTS IN PSYCHIATRY LEADING TO THE CULTURAL FORMULATION INTERVIEW

Although anthropologists and psychiatrists began collaborating with the “culture and personality” school since the 1920s (Kirmayer, 2007), interdisciplinary collaborations achieved institutional recognition when the American Psychiatric Association (APA) prepared its fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In 1991, the APA worked with psychiatrists, psychologists, and anthropologists from a National Institute of Mental Health (NIMH) Group on Culture and Diagnosis to identify cultural factors related to diagnosis (Mezzich, 2008). The group demonstrated that cultural factors influence diagnosis in shaping the content and meaning of symptoms, the rationales for grouping symptoms together, and communication norms (Mezzich et al., 1999).

The group also promoted social constructivist theories for clinical practice. A psychiatrist on the APA’s DSM-IV Task Force argued, “Concentration on the personal experience of the patient is becoming a focus of convergence between anthropological considerations on the cultural matrix of psychopathology and a movement within clinical and social psychiatry” (Mezzich, 2008, 87). Another psychiatrist on the NIMH group called for cultural case studies:

An assessment should contextualize the multiaxial data within a processual view of social relations and institutions. The fundamental challenge that cultural analysis brings to diagnostic thinking is its capacity to render visible the socially constructed context that mediates key features of a patient’s presentation and subsequent course. (Lewis-Fernández, 1996, 135)

The NIMH Group suggested that DSM-IV include an Outline for Cultural Formulation (OCF) for clinicians to organize data in five domains: cultural identity of the individual; cultural explanations of illness; cultural factors related to the psychosocial environment and levels of functioning; cultural aspects of the patient-clinician relationship; and, cultural factors related to diagnosis and treatment (Lewis-Fernández, 1996; Mezzich, 2008; Mezzich et al., 1999).¹

After DSM-IV’s publication in 1994, psychiatrists and anthropologists used the OCF in various ways. Some published studies on how clinicians could adopt the OCF with patients from all backgrounds and identities, consistent with social constructivism (Bäärnhielm and Scarpinati Rosso, 2009). Others saw the OCF as a tool to teach cultural competence in US multiculturalism and diversity programs (Harris et al., 2008; Lim et al., 2008). Psychiatrists and anthropologists abroad developed cultural consultation services based on the OCF for minoritized ethnoracial, immigrant, and refugee patients (Adeponle et al., 2012; Groen et al., 2016; Rohlof et al., 2009). Hence, trends that anthropologists observed in American medicine about cultural competence programs conceptualizing culture differently were mirrored in mental health settings, domestically and internationally.

Clinicians have increasingly recommended cultural formulations for all patients, not just those who are minoritized. In revising psychiatric diagnoses from DSM-IV to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, the APA convened a DSM-5 Cross-Cultural Issues Subgroup (DCCIS) formed mostly by cultural psychiatrists and psychiatric anthropologists. The DCCIS conducted a literature review of studies on cultural assessments in mental health from the period 1965–1994 and case studies on the OCF starting from the year 1994. Examining studies across anthropology, psychiatry, and psychology, the DCCIS suggested that “cultural identity should be explored with reference to context, the recognition of multiple strands or hybridity, and the possibility of change over time” (Lewis-Fernández et al., 2013, 142). This suggestion emerged from case studies (Aggarwal, 2012) that used Homi K. Bhabha’s (1994) poststructuralist theory of hybridity to trace how patients construct understandings of themselves, health, and illness from multiple demographic categories that cannot be reduced to race and ethnicity. OCF-based interviews helped clinicians re-diagnose patients by asking them about their explanatory models of illness within social relationships (Adeponle et al., 2012; Bäärnhielm et al., 2015). Since clinicians found the OCF difficult to use without instructions, the DCCIS created a semistructured CFI (APA, 2013a). A 14-item draft was developed with experts from OCF-based consultation services, field-tested with 321 patients and 75 clinicians in six countries in 2011 and 2012, and revised based on patient and clinician feedback (Aggarwal et al., 2016). Patients and clinicians found the CFI clinically feasible, acceptable, and useful, with all questions completed in as little as 23 minutes (Lewis-Fernández et al., 2017). Anthropologists have called the CFI “inspiring” in applying anthropology to clinical work (Kleinman, 2016).

The revised, 16-item CFI in DSM-5 operationalizes the anthropological recommendation to ask patients about their identities and the relevance of identities to their illness (Kleinman and Benson, 2006) in three questions:²

Sometimes, aspects of people’s background or identity can make their problem better or worse. By background or identity, I mean, for example, the communities you belong to, the languages you speak, where you or your family are from, your race or ethnic background, your gender or sexual orientation, or your faith or religion.

1. For you, what are the most important aspects of your background or identity?

2. Are there any aspects of your background or identity that make a difference to your problem?

3. Are there any aspects of your background or identity that are causing other concerns or difficulties for you? (APA, 2013a)

Twenty-five studies enrolling human participants were published about the CFI globally from 2013 to 2020 (Aggarwal et al., 2020). While some studies have asked patients and clinicians about these identity questions in debriefing interviews, no study has analyzed responses to these questions using direct data from actual patient-clinician sessions. Nor has anthropological scholarship in cultural competence explored interventions with patients (Hannah and Carpenter-Song, 2013; Jenks, 2011; Shaw and Armin, 2011; Willen, 2013; Willen et al., 2010. We used participant observation to fill this gap.

ETHNOGRAPHY AS METHOD: CULTURAL COMPETENCE AT A COMMUNITY MENTAL HEALTH CLINIC

We undertook team-based ethnographic research from 2014 to 2019 through an NIMH-funded grant to study patient-clinician communication at a community mental health clinic (CMHC). State and national trends encouraged this collaboration. New York State’s Office of Mental Health (OMH) published a Cultural Competence Strategic Plan with one objective named as “evaluate the levels of cultural competency in program service delivery” (2010, 12), applicable to all services funded through New York’s public health system. In 2013, the APA’s Board of Trustees passed a resource document, noting that “assessment and treatment processes that define ‘normal’ in the context of the client’s culture” and “developing adequate cross-cultural communication skills” are elements of “culturally competent services” through the CFI (APA, 2013b).

A psychiatrist who chairs a department of psychiatry with funding from New York’s public health system (Chen invited a cultural psychiatrist with graduate and postdoctoral training in applied medical anthropology (Aggarwal) to implement the CFI. The first author, who participated in the CFI field trials, enlisted psychiatrists and anthropologists from the DSM-IV and DSM-5 revisions for consultation (Guarnaccia and Lewis-Fernández). Because neither OMH nor the APA explained what specific skills would be considered “cross-cultural communication skills,” our team agreed that participant observation could illuminate extant clinical practices for improvement (Pope, 2005). The Institutional Review Boards (IRBs) at all sites approved our studies, and all participants provided written informed consent for observations, interviews, and record reviews.

We examined patient-clinician communication at an outpatient mental health clinic that receives referrals from two hospitals through a community network that we call Crown Health Systems (CHS) in Queens.³ Open Monday through Saturday, it employs 30 administrators, psychiatrists, psychologists, nursses, and social workers. The clinic offers individual psychotherapy, group psychotherapy, couples and family counseling, medication management, and case management with referrals to social services for people of all ages. The clinic refers to an emergency room when patients exhibit substance intoxication, suicidal thoughts and behaviors, or homicidal thoughts and behaviors. The outpatient clinic also receives referrals from CHS providers in family medicine, internal medicine, obstetrics/gynecology, and surgery.

CHS’s network rests on over a dozen ambulatory health centers in mostly immigrant and minoritized ethnoracial neighborhoods. According to the 2020 US Census, Queens is the most ethnoracially diverse American urban center: 28 percent of residents are Latinx, 27 percent non-Latinx Asian, 22 percent non-Latinx White, 16 percent non-Latinx Black, and the remainder from other ethnoracial backgrounds (City of New York Department of City Planning, 2021). In 2014, the clinic had about 1500 outpatients; 30 percent identified as White, 30 percent as Latinx, 32 percent as Asian, and 8 percent as Black. At CMHC, interpreters are available on-site for 15 languages, and over-the-phone interpretation is available 24 hours a day in over 200 languages. Each floor has information about interpreters, patient forms in preferred languages, and signs in different languages about patient rights. Patients and clinicians mostly speak Spanish, Mandarin, Cantonese, Korean, or Hindi-Urdu in waiting rooms but usually switch to English for clinical encounters.

CMHC’s five-block radius encompasses three Chinese restaurants, two bodegas advertising “Latino” cuisine, a Muslim halal deli, and a Hindu vegetarian café. Nearby are a Russian Orthodox Church, a mosque, a Roman Catholic Church, two Hindu temples, a Korean Presbyterian church, and a Chinese Buddhist temple. A Guyanese hospital administrator called the neighborhood “The holiest place in the world, where all the gods are welcome!” Nail salons, bubble tea cafés, electronics stores, and restaurants beyond the radius feature signs in Spanish, Korean, and Hanzi, sometimes excluding English altogether. CMHC is in an area marked by “hyperdiversity,” defined as “social settings in which complex interactions among multiple forms of difference and diversity—for instance, race, ethnicity, culture, gender, sexual orientation, and socioeconomic class—intersect in ways that significantly influence efforts to cultivate clinical rapport and trust” (Good et al., 2011, 20).

STUDY DESIGN AND ANALYSIS

These data come from a five-year study of patient-clinician interactions. We spent over 500 hours at CMHC with Aggarwal leading clinical and ethnographic data collection. Recognizing that participant observation requires different research roles (Gold, 1958), Aggarwal sought to understand everyday life at the clinic for four months by sitting in waiting rooms, clinical meetings, IRB meetings, and didactic lessons as clinicians taught trainees in psychiatry, psychology, and social work. Fieldnotes were shared with the research team.

Next, Aggarwal and a research assistant hosted three 90-minute discussions on models of cultural competence in mental health for clinicians and administrators. We conducted three focus groups that separately enrolled eight patients, eight clinicians, and eight administrators to discuss their experiences with cultural competence, CMHC’s cultural competence practices, and how the CFI could fit CMHC’s setting. We conducted individual interviews with focus group participants that lasted 30 to 60 minutes. The focus groups and individual interviews followed a semi-structured format; they were transcribed, and shared with the study team. We learned that all patients attend a 60-minute intake with a social worker or a psychologist (Session 1), a 45-minute appointment with a psychiatrist (Session 2), and a 60-minute first psychotherapy session with a social worker or a psychologist (Session 3) within one month. Clinicians agreed to implement the CFI in Session 1 after administrators gave assurances that a CFI training session would fulfill CMHC’s annual education requirements for cultural competence and all sessions would be billable. We discovered that no clinician asked questions about how patients self-identify and how identities were relevant to illnesses, which all patients in the focus group liked.

Finally, we conducted a clinical trial of clinicians using the CFI with new outpatients versus clinicians who did not use the CFI. Patients were randomized to CFI or control arms; CMHC’s intake coordinator presented the study to all patients on scheduling their first session. The CFI requires clinicians to change behaviors in asking anthropological questions that are not routine. Therefore, we followed the NIMH’s stage model to convert social science theories based on descriptive research into behavioral interventions by conducting a pilot study with the aim of enrolling at least three clinicians and 12 patients in each arm where the focus was on standardizing training procedures with a limited number of clinicians to ensure the intervention’s replicability (Rounsaville et al., 2001). NIMH has endorsed ethnographic studies with at least 30 individuals in a clinical setting, a benchmark we sought to meet (Creswell et al., 2011). Clinicians have not understood how to ask questions about identity when only given a copy of the CFI (Aggarwal et al., 2013; Ramírez Stege and Yarris, 2017), so our trial trained clinicians before patient enrollment through effective practices in adult learning such as reading the entire CFI, watching a video on its use, practicing questions through case simulations, asking Aggarwal questions about unclear usage, and providing feedback after the first case (Beidas and Kendall, 2010). We found that all clinicians asked all patients each CFI question. We oversampled patients in the CFI arm to learn how patients self-identify in settings of hyperdiversity, because oversampling can illuminate poorly understood social dimensions of health (Vaughan, 2017). Patients were excluded if they had acute suicidality or homicidality, dementia, intellectual disability, or psychosis which could interfere with responding to questions. All patients received an honorarium of USD 30 for their time at each session. We recorded consultations for the first three sessions where patients established care and conducted semi-structured, open-ended, debriefing interviews with patients and clinicians in the CFI arm to compare clinical interactions with individuals’ reflections (Kagawa-Singer et al., 2015).

Three clinicians enrolled in the CFI arm, and three others delivered treatment as usual (TAU). Twenty-seven patients enrolled in the CFI arm and 18 patients enrolled in TAU. We recorded 117 patient-clinician appointments and 98 debriefing interviews.

All interviews were transcribed with Aggarwal listening to recordings and checking the transcription again by listening to recordings a second time. We used fieldnotes, interviews with participants, and literature reviews on identity and cultural competence from anthropology and psychiatry to create a coding scheme. We entered transcripts and fieldnotes into NVivo and followed analytical triangulation to check codes against literature reviews and patient medical charts (Myers and Ziv, 2016). Lewis-Fernández checked Aggarwal’s coding so that inter-rater reliability exceeded 90 percent, with discrepancies resolved through consensus with the other co-authors.

RESULTS

Tables 1 and 2 present sample characteristics. Participants predominantly identified as female. Patients were younger, from minoritized ethnoracial communities, and mostly born in the United States, compared to clinicians. Most patients had less than a bachelor’s degree, and slightly fewer than half had sources of income other than employment. More Latinx and non-Latinx Black patients enrolled in our trial than CMHC’s typical outpatients.

TABLE 1.

Demographic characteristics of six clinicians.

Sex
Male	1
Female	5
Age range (38 to 67 years; mean 51.4 years)
30–39	1
40–49	1
50–59	2
60–69	1
Refused to answer	1
Race/Ethnicity
non-Latinx White	2
Latinx	2
non-Latinx Asian	2
Job title
Social worker	4
Psychiatrist	2
Years as a clinician
1–5	1
6–10	2
11–15	1
>15	2
Nativity
Born abroad	4
Born in the United States	2
Primary language
English	1
Other	5

TABLE 2.

Demographic characteristics of 45 patients.

Sex
Male	18
Female	27
Age range (18 to 67 years; mean 33.3 years)
<20	3
20–29	23
30–39	6
40–49	5
50–59	6
60–69	2
Race/Ethnicity
Latinx	19
non-Latinx Black	15
non-Latinx Asian	5
non-Latinx White	4
Multiracial	2
Nativity
Born abroad	11
Born in the US	34
Primary language
English	34
Other	11
Education
Some high school	20
Some college	15
Bachelor’s degree	5
Any graduate school	3
Chose not to answer	2
Source of income
Employment	20
Family assistance	10
Disability	5
Public assistance	5
Pension	1
Chose not to answer	4

Unlike settings where clinicians ascribe a gender, race, and ethnicity to a patient based on physical characteristics, CMHC’s intake coordinator recorded this information after asking patients, with categories drawn from the US Census. The intake clinician also asked patients about gender, race, and ethnicity in the first session. With patients in TAU, no clinician discussed identity. But in the CFI arm, when clinicians asked patients about the most important aspects of their identity and we compared all 27 patient responses in clinical sessions to entries in the Electronic Health Record (EHR), we discovered four possibilities: patient self-identifications exactly matched EHR responses (n = 9); patients self-identifications differed from EHR responses (n = 9); patient self-identifications encompassed but exceeded EHR responses (n = 5); and patients could not prioritize a single self-identification (n = 4). When clinicians asked if self-identifications were affecting their presenting problem, 18 patients said yes and 9 said no. In the following sections, we present representative case studies.

When patient responses exactly matched Electronic Health Record responses

Ms. Rodríguez, a 23-year-old student, checked “Hispanic/Latinx” and “female” on the demographic form. Her intake clinician, a non-Latinx White male social worker, asked why she wanted to establish care. She said, “For life therapy—to get my life on track and medication.” Difficulties with focus impaired her education: “I have to take a remedial math class, and then from there I want to go to nursing school. But I have to take an exam.” Her clinician asked about problems with focusing, and Ms. Rodríguez answered,

I was in special education my whole life. They never told me what I had—they just said learning disability. I’ve been disorganized. I don’t clean up my room and I always lose track of things. The other day, I forgot my phone in the house and a metro card. It could be simple stuff like that. I’ve been procrastinating on everything. I don’t do certain things. I haven’t filed my taxes yet. I haven’t gotten my driver’s license yet.

She said that her mother was not supportive: “I live with my mom. She calls me lazy. I don’t think I’m lazy. I’m very disorganized.”

The clinician asked about the most important aspect of her background and identity:

Ms. Rodríguez: I guess Hispanic, right? That’s my identity.

Clinician: Was your mother born here?

Ms. Rodríguez: No, she wasn’t born here.

Clinician: Where was your mom from?

Ms. Rodríguez: Dominican Republic.

Clinician: And your father was from the Dominican Republic?

Ms. Rodríguez: No, he was from Colombia.

Clinician: So those are both Latin countries. But there are probably some similarities and differences. How do you identify? Do you identify as more Dominican or Colombian or a mix?

Ms. Rodríguez: A mix, I guess. Yeah. I mean, I don’t really speak Spanish though.

Clinician: So you identify as a Hispanic woman with Colombian and Dominican background?

Ms. Rodríguez: Yeah.

Clinician: So being a Hispanic woman, how does that make a difference to your learning disability? Does it help you in any way?

Ms. Rodríguez: No, it doesn’t help. Maybe if I was White, it would be different.

Clinician: How would it be different?

Ms. Rodríguez: I would have gotten help sooner.

Ms. Rodríguez’s stated and recorded identities were identical. She did not voice a strong connection to her parents’ countries of origin or linguistic heritage. However, she believed she could have received care earlier if she were White for what was diagnosed for the first time as attention-deficit/hyperactivity disorder. After her third session, we debriefed her clinician on identity questions, and he said,

There needs to be some way to assess what the patient is thinking because I think it’s dangerous to just make assumptions based on race or gender or whatnot. Just because a person might be Dominican doesn’t mean all Dominicans share the same cultural values.

When patient responses differed from Electronic Health Record responses

Ms. Arora, a 28-year-old woman, showed how demographic categories did not match lived experiences. She checked “West Asian/Middle Eastern,” though this identity did not capture how she saw herself in religious, migratory, or generational terms. When her intake clinician, a non-Latinx White male social worker, asked why she came for care, she said, “For the last year, two years max, I’ve gone downhill. I used to be very happy, very upbeat, very confident, very hopeful. Now, I don’t have hope. I don’t know where my life is going. I have panic attacks.” She described her trigger as “I think I’m getting attacked. It started at work, at my last job in retail. Somebody would be bullying me. A manager wasn’t giving me a promotion I deserved.” Her clinician asked what troubled her most, and she said, “It used to be my career, but now it’s more about love and relationships.” She described one ex-boyfriend: “He started criticizing my body—he would ask, ‘Why is your hair like that? You’re not like a sexy supermodel. Why can’t you lose weight?’ It turned into fat shaming.” His perception affected her self-image:

I was going through something with myself because of him. I started to believe that I would never find love again. That no man would ever love me because I am fat, I’m ugly, and I’m not like those pretty, high-class girls that he wanted. I would wake up having panic attacks and anxiety.

The clinician asked her about the most important aspects of her identity:

Ms. Arora: My parents came from Afghanistan. I’m thankful that I’m an American and can be here in New York. My God, if my parents never emigrated here, where the hell would I be? Over there.

Clinician: Why did they come?

Ms. Arora: To find happiness. To find freedom. I guess Afghanistan was just going downhill back in the ‘80s.

Clinician: Were they persecuted in any way? Like for their religion?

Ms. Arora: I guess so at the beginning stages. My parents came here in 1983 or ‘84. I was born in 1988. My dad just wanted to make money. He wanted to start a business. Everybody was like, “America—that’s where you go. American dream.”

Clinician: Right. Are there any aspects of your background or identity that make a difference to your problem?

Ms. Arora: I love the concept of marriage. My parents are happily married. Everybody in my family is married. When you marry, you marry for life. There’s no mention of divorce. Divorce is not an option. We never even learned about divorce being an option or breakups.

Clinician: How did your parents meet?

Ms. Arora: My dad had a crush on my mom. They started talking, they fell in love, and then he asked for her hand in marriage from my grandpa. I guess I want to be married too. Like from an ethnic point of view, after age 24 or 25, a girl should be married.

Ms. Arora described her view of religion: “I work in Manhattan. I go to church after work. I believe in Jesus. I just love going to church so I can talk to God and have that moment with him.” Her clinician asked if she was born into a Christian household, and Ms. Arora said, “My family was born in Afghanistan. We’re a minority religion. We’re Hindu, but most Afghans are Muslim. My family has Sikhs and Buddhists in it too. It’s kind of strange.” She acknowledged,

I keep my personal beliefs to myself. My mom goes to the Hindu temple and believes in it. I believe aspects of it, like karma or reincarnation, but I feel more drawn to Christianity for some reason. Maybe it’s because I was born and raised in America and my friends are Christian.

We debriefed Ms. Arora after her first session about the identity questions. She said,

Cultural identity really affects me. That’s one of the reasons why I’m depressed. I want to get married; I want to have children. I want to move on and go up in life. My parents—they just gave up; to them, coming to America was enough.

Her cultural identity could not be encompassed in demographic forms, yet shaped cultural ideals about romantic relationships the problems of which triggered panic attacks.

When patient responses included but exceeded Electronic Health Record responses

Ms. Williams, a 51-year-old woman, checked “Black/African American” and “female” on the demographic form. She finished an intensive outpatient program with thrice-weekly appointments over nine months to treat alcohol use disorder. When the intake clinician, a non-Latinx White social worker who identified as Eastern European, asked why she wanted to establish care, Ms. Williams said, “I’ve been in the process of getting a new therapist and getting a new doctor. I’m bipolar and I’m very stable on my bipolar medications. I have no complaints. I have felt really great for quite some time.” She had been in treatment for 20 years and received social security disability after two hospitalizations for attempting suicide.

The clinician asked why she thought she had developed bipolar disorder. Ms. Williams replied, “I had a suicidal mother, and my father wasn’t around. My mother is schizophrenic, so I knew it was biological.” Her mother’s suicide attempts had an impact on familial relationships:

I never saw her overdoses on pills, but the traumatic separation and her just being gone, I would end up with relatives. There was no contact. My mom and dad separated around that time, so I lost all my family in a matter of months.

When the clinician asked whether people in her life understood her, Ms. Williams replied,

My significant other, my fiancé, he understands. My children understand. But my close girlfriends don’t really understand. They know I get depressed sometimes, but they think, “Well, we’ll go out to lunch or we’ll go out someplace and you’ll get better.”

Ms. Williams explained how a biomedical explanatory model helped her: “What was most helpful to me was going into recovery and stop using alcohol. It had a big impact on my mental health and the balance, the chemistry in my brain.”

The clinician asked about the most important aspect of her background and identity:

Ms. Williams: We live in a time where things are very different from 30–40 years ago. There’s a lot of different ethnic groups here. I live here in Queens, Flushing, and sometimes I feel very isolated, you know, because of my race and living among such a heavily populated Asian community. So I do not sometimes feel a part of it.

Clinician: Because of your race?

Ms. Williams: Because of my race.

Clinician: Are there any aspects of your background or identity that make a difference to your bipolar disorder?

Ms. Williams: Well, I’m a Christian, I’m a Baptist. That’s a part of my identity. I’m happy with that.

Clinician: Do you find that your faith helps you cope?

Ms. Williams: Yes, it does.

Clinician: How would you describe your spiritual or religious beliefs?

Ms. Williams: I’m very spiritual. I believe in a power higher than myself. I pray to God.

Clinician: In what ways is religion important in your life?

Ms. Williams: I meditate and I look for positive energy. I’ve experienced positiveness in my faith.

Clinician: Are there any aspects of your background or identity that are causing other concerns or difficulties for you?

Ms. Williams: Well, I feel like we live in racial times. A lot of Black men are being killed and there just seems not to be much justice. It happens one week here, and the next week there, and then the next week there. Not everybody is innocent, but I feel like people wake up and thank God that they are not Black.

For Ms. Williams, her son’s criminal justice involvement affected her mental health:

I was a single parent, and I had a son who was constantly getting in trouble like from the age of 14 to 18. It was five years of just the court system, money, and just everything. I ended up having to resign from my job. I was a counselor in a residential facility for at-risk kids who were mandated for drugs and stuff like that. And I couldn’t help him. I did this work for a living, and I couldn’t help my own son. It was just heart breaking, heart wrenching to think that I would lose him. I was fighting against the world. I began to drink just casually. One drink here, a drink after work, one at dinner, and one when I go to bed.

She refused her son shelter but praised the church for housing him, explaining, “He works in a restaurant. He stays at a church. Everybody has to work.”

We debriefed after her intake. She said, “I had some feelings culturally as an African American in the United States feeling a little alienated where I live. I’ve been here for 17 years. I do feel, at times, very different, not belonging.” We asked why she thought that questions about identity were helpful, and she said,

It helped me say something I’ve felt for quite some time. You know the images about Black people in general. Having therapy with someone from another country, from a totally different culture—and all they know about me as a Black person is what they see on TV. I feel that at some points in therapy that we can get separate.

When we debriefed after her third appointment, she indicated that she liked working with someone from another country in psychotherapy, saying, “Today’s session was great. I really like her. Treatment’s been going fine.”

When patients could not prioritize a single self-identification

Mr. Kowalski, a 44-year-old man born in Poland, checked “White” and “male” on the demographic form. He had been in the United States for 16 years and had never sought mental health care. His intake clinician, a non-Latinx White social worker, asked why he presented to the clinic, and Mr. Kowalski replied, “I’m just unable to work right now. Sometimes I’m having attacks where I cannot really make a decision about simple things. I have to reread things at work.” His clinician asked about his work, and Mr. Kowalski answered, “I’m a tile and stone setter. Sometimes the products are going into millions of dollars and I’m responsible for over 25 people. I have to make quick decisions and I’m having problems lately with those things.” He attributed his sadness over several days to his immigration status:

My immigration status is part of the story because I’m in the process of getting the green card for the last 15 years. I’ve spent almost $50,000 on it. I was up and down this whole roller coaster with 15 different cases, seven lawyers.

The clinician asked about the most important aspect of his identity:

Mr. Kowalski: In the very beginning, it used to be European culture and the Polish community. But right now I don’t feel a part of it because I was never active in the Polish community. We didn’t actually keep like close ties with the rest of the community.

Clinician: Did you come here by yourself or did you come with friends or family?

Mr. Kowalski: No, I came with my wife. We married here, but I knew her for more than 15 years from college.

Clinician: In Poland?

Mr. Kowalski: Yes

Moderator: Are there any aspects of your background or identity that make a difference to your overwhelming feelings?

Mr. Kowalski: Sometimes the fact that I’m not in my own country could be a trigger.

Clinician: Do you feel homesick?

Mr. Kowalski: No, not really. I wouldn’t say so. But sometimes, I don’t feel like I belong here.

Clinician: Do you think that’s due to your immigration status?

Mr. Kowalski: Not really, but it’s somewhere there in the background.

Mr. Kowalski described frustration with being “stuck” between both societies:

I’m supposed to go back to Poland and sort things out. But if I go back to Poland, I’m going to just destroy my case here and I’m really close—like a year or so—to finally getting the green card. And I cannot redo it.

After the intake, we debriefed both Mr. Kowalski and his clinician about identity questions. Mr. Kowalski said, “He was trying to find the connections between culture, family, and my background. That was something unusual for me. This is my first time in care, so I have no idea what to look for.” His clinician acknowledged that Mr. Kowalski could not prioritize a single self-identification which would help formulate the clinical problem:

I think he was kind of beating himself up. It’s like, “Well I should have stayed connected to my community.” It seems like that in the last year he feels more trapped here and unable to go to Poland with his legal situation.

DISCUSSION

In 2005, Susan Shaw wrote, “Advocates for culturally appropriate health care must move beyond straightforward ideas about resemblance to develop more complex ways to modify systems of care to better respond to diverse patients” (2005, 305–6). This article has traced how anthropologists and psychiatrists have developed complex ways through theories like social constructivism, multiculturalism, and hybridity that have gained support from professional organizations such as the APA. When permitted to narrate their self-understandings, most patients differed in presenting themselves on paper and in person. Two-thirds of patients connected their identities to illness, indicating the usefulness of these questions, even for individuals like Ms. Rodríguez who perceived her identity through disparities in receiving a diagnosis. The Association of American Medical Colleges (2022) has called for assessment methods and scholarship on diversity, equity, and inclusion across medicine, and interview tools that anthropologists have helped to develop—such as the CFI—have been used in medical settings outside of mental health (Aggarwal et al., 2020).

Our work contributes to cultural competence scholarship. Anthropologists have shown that cultural competence initiatives often encounter clinician resistance (Hannah and Carpenter-Song, 2013; Willen, 2013; Willen at al., 2010. In contrast, our clinicians and patients remained receptive throughout our study. Setting characteristics could account for differences—those studies occurred in academic centers where faculty offered didactic instruction to resident trainees without patient interactions. Our research followed independent clinicians treating patients in a hyperdiverse community health center. Ms. Arora valued the opportunity to share self-identifications that differed from the clinic’s and her family’s presumptions, just as Ms. Williams shared concerns about her neighborhood. Our work challenges assumptions of some anthropologists that patients can name a single, most important, self-identification (Kleinman and Benson, 2006), as exemplified by Mr. Kowalski’s interstitial American, European, and Polish identity, despite his portraying himself initially as “White.” In the 2010s, anthropologists critiqued cultural competence pedagogies for placing the responsibility of alleviating health disparities onto individual providers by cultivating forms of “ethical self-fashioning” (Shaw and Armin, 2011) or “open-mindedness” (Jenks, 2011) without addressing political, economic, and social structures. Our work signals political momentum as evidenced through OMH’s requirement for cultural competence initiatives in New York’s public mental health system, though how such policies redress structural inequities needs further investigation.

Our findings differ from studies abroad. Patients and clinicians in Mexico did not understand questions on background or identity (Ramírez Stege and Yarris, 2017), but it is unclear if that is due to insufficient training since clinicians were resident trainees and only given a copy of such questions to read without practice. Clinicians in Denmark who were trained for one hour found the questions to be “Othering” of patients (Lindberg et al., 2022), but patients valued the opportunity to articulate their identities (Lindberg et al., 2021). Our training incorporated practicing questions, a question and answer session, and feedback after the first case. Both research groups also used translations without reporting on the construct or linguistic validity of questions. Perhaps independent clinicians are receptive to a cultural competence approach with patients after training. Future work can clarify differences in reception.

Our work also shows how the CFI responds to “structural competency.” Jonathan M. Metzl and Helena Hansen (2014) proposed this term to more systematically train health-care professionals to think about how such variables as race, class, gender, and ethnicity are shaped both by the interactions of two persons in a room, and by the larger structural contexts in which their interactions take place. (127)

Discussions of identity revealed clinical symptoms within social, political, and economic structures. Ms. Rodríguez spoke of the stigma of having a learning disability. Ms. Arora recounted anxieties around gendered social attitudes of body image. Ms. Williams narrated concerns about a changing neighborhood, and how her son’s criminal justice involvement led to substance use. Mr. Kowalski described sadness as a consequence of America’s immigration system. In each case, the CFI elicited sociostructural forces that situated patient-clinician interactions.

We recognize our work’s limitations. First, this study occurred at a single site and may not be generalizable. The NIMH recommends pilot interventions based on the social sciences to maximize internal validity, clinician feasibility, and patient acceptability (Rounsaville et al., 2001). Our years-long engagement with CMHC has positioned us to analyze multiple forms of data—participant observation, medical records, patient-clinician sessions, and individual debriefing interviews—to optimize internal validity. Second, we enrolled only those who agreed to speak English in sessions. This could reflect a higher degree of patient acculturation than in the clinic’s general population. Third, we did not examine the effects of sessions on diagnoses or ongoing care. Nonetheless, we affirm the value of patients articulating understandings about themselves and illnesses on their own terms, consistent with centering patient voices in the social sciences (Myers and Ziv, 2016).

Despite these limitations, our study builds on a decades-long tradition of translating anthropological theories for clinical use while also subjecting them to ethnographic critiques. The anthropologist Angela Jenks (2011) insists that “Increased attention must be paid not just to how cultural competence is taught but to how it is learned” (230; emphasis in original). We suggest increased attention to how cultural competence is used in patient-clinician interactions. With sufficient training, clinicians can ask cultural identity questions enabling patients to give full answers and increase understanding, which, in turn, improves rapport. Recent work on the CFI shows improvements in quality of care such as enhanced patient-clinician rapport (Aggarwal et al., 2020) and appointment retention compared with TAU (Aggarwal et al., 2022). We propose that anthropological theories embedded in the CFI and ethnographic methods can facilitate patient-clinician discussions on identities and clinical symptoms within social, political, and economic contexts in addition to improved service outcomes. Our work provides a way to explore the culture–structure intersection in cultural competence interventions.