Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience. These features of culture make it cru- cial not to overgeneralize cultural information or stereotype groups in terms of fixed cul- tural traits.
Race is a culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits attributed to some hypothetical intrinsic, biological characteristics. Racial categories and constructs have varied widely over history and across societies. The construct of race has no consistent biological definition, but it is socially important because it supports racial ideologies, racism, discrimination, and social exclusion, which can have strong negative effects on mental health. There is evidence that racism can exacerbate many psychiatric disorders, contributing to poor outcome, and that racial biases can affect diagnostic assessment.
Ethnicity is a culturally constructed group identity used to define peoples and communi- ties. It may be rooted in a common history, geography, language, religion, or other shared characteristics of a group, which distinguish that group from others. Ethnicity may be self- assigned or attributed by outsiders. Increasing mobility, intermarriage, and intermixing of cultures has defined new mixed, multiple, or hybrid ethnic identities.
Culture, race, and ethnicity are related to economic inequities, racism, and discrimina- tion that result in health disparities. Cultural, ethnic, and racial identities can be sources of strength and group support that enhance resilience, but they may also lead to psycholog- ical, interpersonal, and intergenerational conﬂict or difficulties in adaptation that require diagnostic assessment.
The Outline for Cultural Formulation introduced in DSM-IV provided a framework for as— sessing information about cultural features of an individual’s mental health problem and how it relates to a social and cultural context and history. DSM-S not only includes an up- dated version of the Outline but also presents an approach to assessment, using the Cul- tural Formulation Interview (CFI), which has been field-tested for diagnostic usefulness among clinicians and for acceptability among patients.
The revised Outline for Cultural Formulation calls for systematic assessment of the fol- lowing categories:
I Cultural identity of the individual: Describe the individual’s racial, ethnic, or cultural reference groups that may inﬂuence his or her relationships with others, access to re- sources, and developmental and current challenges, conﬂicts, or predicaments. For im- migrants and racial or ethnic minorities, the degree and kinds of involvement with both the culture of origin and the host culture or majority culture should be noted separately.
Language abilities, preferences, and patterns of use are relevant for identifying difficul- ties with access to care, social integration, and the need for an interpreter. Other clini— cally relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual orientation.
0 Cultural conceptualizations 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 dis- tress, 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 individ- ual’s cultural reference groups. Assessment of coping and help-seeking patterns should consider the use of professional as well as traditional, alternative, or complementary sources of care.