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Cultural assessment

The guidelines for cultural assessment and formulation are intended to help the consultant collect, organize and integrate information pertinent to a cultural consultation. Two versions are presented:

Version A, developed by the Cultural Consultation Service at the JGH, is an elaboration of the cultural formulation in DSM-IV. The first sections summarize information usually collected in a comprehensive psychiatric history but with questions added to address common issues and experiences for immigrants, refugees and members of ethnocultural minorities. The crucial section focuses directly on the cultural formulation.

Version B, developed by the Transcultural Child Psychiatry Clinic at the Montreal Children's Hospital, is designed as a semi-structured interview to be used by a researcher interviewing a clinician/consultant after the fact. As a result, it is more retrospectively focused, aimed at reconstructed a case that may have been followed in treatment for some time.

Cultural Assessment Outline: Version A

Clinical History

A. Referral

1. Reasons for referral: (quote referring person's own words)

2. Referral source: (specify clinic/institution, person/clinician, profession)

__ patient (self-referred),

__ family, migrant and refugee health services,

__ GP

__ medical specialist

__ psychologist

__ social worker

__ lawyer

__ CLSC

__ emergency ward

__ pediatric ward

__ school

__ other

3. How did the referral source learn about the existence of the Cultural Consultation Service (CCS)?

4. Does the referral source know a particular person associated with the CCS?

5. How was the suggestion for referral received by the patient/family?

6. How did the triage process take place? (List all applicable)

__ From within institution? (ER, OPD, Screening clinic, Staff member, etc.)

__ Call by patient/family to psychiatry general intake?

__ Call by referring person to general psychiatry intake?

__ Call by patient/family to a member of the CCS?

__ Call by referring person to the CCS?

B. Patient Identification

  1. age
  2. sex
  3. religion
  4. country of origin
  5. languages spoken, primary language spoken at home
  6. parent's occupation, current and past
  7. citizenship & immigration status
  8. length of stay in Canada
  9. moves in Canada
  10. who lives at home
  11. children's school and grade
  12. language of instruction at school
  13. eligibility certificate option

C. Presenting Problem

1. Describe in the patient's/family's own words.

2. Note duration

D. Setting of Evaluation

1. Who was present at the assessment interviews?

Family members (list all present)

Team members (list all present)

If more than one team member present, what were their roles in the interview?

Culture brokers or interpreter:

__ family member acting as interpreter

__ professional interpreter

__ other (specify) _____________________________________)

2. What was the physical setting of the assessment interview?

Institution

Room/space

Seating pattern

Use of one-way mirror, video, recording, etc.

E. History of present illness

  1. Nature of problem
  2. Symptoms described
  3. Evolution of problem
  4. Level of function at home, work, with friends, extended family, community
  5. Previous help-seeking for problem
  6. Did the patient/family consult a medical specialist for the present problem?
  7. Did the patient/family consult alternative resources for the present problem?

F. Past Medical History

  1. major illnesses, injuries, disabilities
  2. hospitalizations
  3. surgeries
  4. medications
  5. drug or alcohol use

G. Psychiatric History

  1. Previous involvement with psychiatry, psychologist, other mental health professional, social worker, school counselor
  2. What was the problem at that time?
  3. What formulation of the problem was offered to the patient/family (e.g. DSM- IV, other)?
  4. Previous treatments (medication, hospitalization, psychotherapy, family therapy, other interventions.)
  5. Was the treatment successful or not?

H. Family History

  1. Identify people living together in household
  2. Identify any nuclear family members not living together (e.g., left behind in country of origin)
  3. Did any family member have a mental health difficulty?
  4. How was this difficulty managed/treated?
  5. Did anyone have a problem similar to the identified patient's?
  6. Relevant family events and stresses (e.g. death, loss or separation, chronic illness or disability, imprisonment or threat of imprisonment, harassment)

    Patient's Family: Mother's/Father's family

  7. Where was mother/father born?
  8. birth order in family
  9. number of siblings
  10. What was mother's/father's relationship with her/his father like?
  11. … with her/his mother?
  12. Is there a history of migration in mother's/father's family?
  13. Trauma due to political violence?
  14. A history of parent child separations?

    Marital History (if applicable)

  15. How did the couple meet?
  16. How old were they?
  17. Are they married?
  18. Was the marriage arranged?
  19. How did both families accept the union?
  20. Was either partner previously married?
  21. Does either partner have other children?

    Children's History (if applicable)

  22. How were the children's names chosen?
  23. What do their names mean?
  24. Are there other children in the family whom they are responsible for? (e.g. fostered, adopted)
  25. How are they related to the couple?
  26. Were there children born since their arrival to Canada?
  27. Does the child have a filial or emotional bond with adults other than the parents? (e.g. maternal uncle in some matrilineal cultures; mid-wife, etc.)

    Migration history

    28. Ìý

  28. What are the couple's countries of origin?
  29. When did they leave?
  30. Why did they leave?
  31. Who decided to leave?
  32. What was their migration route to Canada?
  33. Did they live in a refugee camp? For how long?
  34. What was their perception of their migration experience?
  35. Were family members left behind?
  36. Were their children left behind and with whom?
  37. Did their children travel separately?
  38. Were they accompanied?
  39. Are there plans to reunite with family members who stayed behind?

I. Social & Developmental History

J. Family Assessment

  1. pertinent mental status of family members
  2. communication issues
  3. instrumental functioning
  4. problem solving skills

K. Mental Status Exam

L. Psychological Testing

  1. past
  2. current

M. Other Investigations

  1. Laboratory tests
  2. Other

N. Diagnostic formulation at assessment (DSM Axes I-IV)

Cultural Formulation

A. Cultural Identity

1. Cultural reference group(s)

  1. ethnocultural and religious groups with which the patient self-identifies
  2. other ethnocultural background the patient may not explicit identify with
  3. father's ethnocultural and religious background
  4. mother's ethnocultural and religious background

2. Language(s)

  1. Languages spoken while growing up
  2. Language(s) currently spoken between patient and family
  3. Language(s) spoken at work
  4. Language(s) spoken in health care settings
  5. Language(s) in which patient literate?

3. Cultural factors in development

  1. involvement with siblings,
  2. involvement with peers
  3. social activities

4. Involvement with culture of origin

  1. Contact with family or friends in country of origin
  2. Involvement with community organizations
  3. Does patient attend a group with peers of his culture of origin (e.g. religious organization or leisure setting)?
  4. Does patient have friends from his culture of origin ?
  5. Does patient socialize with extended family members?
  6. What is patient's perception of his culture of origin?

5. Involvement with host culture

  1. Does patient attend a group with peers of host culture (e.g. work, religion, leisure etc)?
  2. Does patient have host culture friends?
  3. What is patient's perception of host culture? Has s/he experienced racism?

B. Cultural Explanations of the Illness

1. Predominant idioms of distress and illness categories

2. Meaning and severity of symptoms in relation to cultural norms

  1. of cultures of origin
  2. of host culture

3. Perceived causes and explanatory models

  1. prototypes (self, other, media)
  2. cause
  3. course
  4. mechanism
  5. expected outcome
  6. treatment

4. Help-seeking experiences and plans

  1. with the formal health care system
  2. with traditional healers and alternative services

C. Cultural Factors Related to Psychosocial Environment & Levels of Functioning

1. Social stressors

  1. Current political situation in country of origin and in host country
  2. What does individual/family feel is the worst stressor?
  3. Taking into account cultural norms and social and family structure, what unique stressors can the clinician identify?

2. Social supports

  1. What are the most important past and current sources of support for the individual/family?

3. Levels of functioning and disability

  1. at home
  2. in extended family
  3. community of origin
  4. host community
  5. school
  6. at work
  7. with peers

D. Cultural Elements of the Clinician-Patient Relationship at Assessment

  1. What is the clinician's ethnocultural background ?
  2. Does the clinician speak the patient's language?
  3. Does the clinician have specific knowledge about the patient's culture?
  4. What is the history of the relationships between the patient's culture of origin and the clinicians' (e.g. colonization, sociopolitical conflict, local history and conflict, racism)?
  5. Was this issue addressed or not?
  6. Were there any value conflicts between the clinician and the patient?

E. Overall Cultural Assessment

  1. Go back over each category above and draw out implications for the case.
  2. What role do social and cultural factors play in this patient's problems and their potential solutions?
  3. Did the migration history play a role in the patient's problems and their potential solution?
  4. Did cultural factors change the formulation or /assessment of the…
  5. (Please check all that are applicable and describe)

__ diagnosis

__ judgement of illness severity

__ rating of level of functioning

__ rating of level of social supports

__ rating of level of stressors

__ prognosis

__ treatment plan

__ therapeutic alliance

__ method of communication with client or family

__ involvement of others in treatment

__ family

__ community

__ traditional or alternative healers

Treatment Plan

Please check all modalities in the recommended treatment plan for this case.

A. Therapeutic Modalities

Medical (Referral)

__ GP

__ Specialist?

Psychiatric Intervention

__ pharmacotherapy

__ psychotherapy ( individual, group, family, play therapy, art therapy, other)

__ Was an interpreter involved? (if yes go to interpreter questionnaire)

__ Was a time frame given in advance (e.g. short or long term)?

Religious

__ internal (e.g. prayer, home shrine)

__ institutional

Legal

__ provision of psychological expertise

__ liaison with lawyer

__ provision of supportive letter

__ appearance at court

Community

__ Referral to key member of person's cultural community

__ Referral to community aid organizations

__ Reinsertion into community of origin, host community, other communities

Ìý

Traditional

Where was treatment sought:

__ country of origin

__ host country

__ transnational network?

Was traditional healing provided by person's culture of origin or another cultural tradition?

Cultural Assessment Outline: Version B

Cultural Consultation Service Evaluation

Montreal Children's Hospital

I. Referral

  1. From the perspective of the referring person, what were the reasons for the referral?
  2. How did the referral source learn about the existence of the CCS?
  3. Does the referral source know a particular person associated with the CCS?
  4. How was the suggestion for referral received by the family?

II. Triage Process

  1. Were there any particular problems associated with the triage process (e.g. missed meetings, apprehensions about coming in, etc.). [Probe What were the reasons for the problems (expressed or implicit) e.g. family member did not want to come, problems due to language or transportation, fear of psychiatric stigma etc.].
  2. What was the time lapse between the referral and the patient's request for appointment? Between the request and the evaluation? Were there any particular problems/factors that influence amount of time between these steps?

III. Evaluation

A. Setting

1. Was an interpreter/culture broker present?

=>If interpreter/culture broker present:

2. Where was interpreter/culture broker hired from (interpreter bank or other?)

3. Were there any problems or issues regarding the role or acceptability of interpreter/culture broker? (Conflicts or alliances between interpreter and family, or the interpreter and team?) [Probe: was interpreter from different national, ethnic, class, religious, political group than family? Were there gender issues?]

4. Did all family members speak the language of origin during the evaluation?

=>If interpreter/culture broker not present:

  1. Which language was spoken, why, and was it used by everyone throughout the evaluation?
  2. Did the clinician or a person on the team have a specific knowledge about the persons culture of origin or speak their language, and did this have any particular impact on the evaluation?
  3. Was there anything special/odd/outstanding about the evaluation? [Probe: language problems, power dynamics between family members, value conflicts between the clinician team and the patient, between family members, sociopolitical conflict? Were these made explicit, were they addressed?]
  4. How did the child participate in the interview (e.g. playing with siblings, alone, sitting with a parent, talking with interviewers).
  5. Attachment behaviors shown by the child: to parents (showing affection, comfort seeking, asking for and accepting help; reunion responses (if child was seen alone); to interviewer (appropriate wariness followed by attempts to relate; engaged too soon, did not engage at all; overly friendly and indiscriminate attachment seeking).
  6. Was the child seen alone? Why or why not? How did s/he react, engage the team?

B. Presentation of problem at evaluation

  1. In general, how did the family present the overall problem during the evaluation? [Probe: Did different family members explain it differently? If so, how? Did one person speak more than another? Were there disagreements or discrepancies within the family concerning the nature of the problem?]
  2. Was the problem different from that presented by the referring person, and how (how did they explain the purpose of their visit?)
  3. Evolution of problem: did the patient/family describe previous help-seeking behavior for the problem, if so where (medical specialist, alternative resources, traditional healer)? How did they describe the results?
  4. What symptoms were described [Probe: was the problem explained only in terms of the child or in terms of other family members as well? Was the problem described as behavioral, biological, psychological, or other?]
  5. What cultural idioms of distress and illness categories were evoked by the family members, or by the team? [Probe: what were the perceived causes and explanatory models given by the family (in terms of host culture, in terms of home culture), and were there discrepancies between family members? Were cultural explanations given spontaneously by the family at this time or were they elicited by the team?]

C. Team Interpretation

  1. What was the team's assessment of the problem following the initial evaluation? Were there disagreements among the team?
  2. How was the meaning and severity of symptoms assessed by the team in relation to cultural norms of the culture of origin, of the host culture?

IV. Family Narrative (as recounted by clinician retrospectively)

A. Past Medical or Psychiatric History

  1. Had the patient suffered from major illnesses, disabilities, injuries, hospitalizations, surgeries? Were they on any medication, was there any problem with drugs/alcohol?
  2. Previous help-seeking experiences (with formal health care system, with alternative or traditional services)
  3. Did patient have previous involvement with psychiatry, psychologist, other mental health professional, social worker, school counselor, Department of Youth Protection?
  4. If yes, what was the problem? What formulation of the problem was given to the family (DSMIV or other?)? What treatment was offered at the time (medicalization, hospitalization, psychotherapy, family therapy, other?) What were the results?

B. Family History

Mother's/Father's Family

  1. Where was mother/father born? What is country of origin?
  2. birth order in family
  3. number of siblings
  4. who was mother/father living with in home country?
  5. What was mother's/father's relationship with her/his father like?
  6. … her/his mother?
  7. Is there a history of divorce or marital separation?
  8. A history of parent child separations?

    9. Marital History

  9. How did the couple meet?
  10. How old were they?
  11. Are they married?
  12. Was the marriage arranged?
  13. How did both families accept the union?
  14. Was either partner previously married?
  15. Does either partner have other children?
  16. What was the household composition/living setting in country of origin prior to migration?

    17. Children's History

  17. How were the children's names chosen?
  18. What do their names mean?
  19. Are there other children in the family whom they are responsible for? (e.g. fostered, adopted)
  20. How are they related to the couple?
  21. Were there children born since their arrival to Canada?
  22. Does the child have a filial and/or emotional bond with adults other than the parents? (e.g. maternal uncle in some matrilineal cultures; mid-wife, etc.)

    23. Family Mental Health History

  23. Did any family member have a mental health difficulty, in country of origin or in Canada?
  24. How was this difficulty managed/treated?
  25. Did anyone have a problem similar to the identified patient's?

C. Migration and Trauma

Migration History

  1. Prior to coming to Canada was there a history of migration in mother's/father's family?
  2. When did they leave the home country?
  3. Why did they leave?
  4. Who decided to leave?
  5. What was their migration route to Canada?
  6. Did they live in a refugee camp? For how long?
  7. What was their perception of their migration experience?
  8. Were family members left behind?
  9. Were their children left behind and with whom?
  10. Did their children travel separately?
  11. Were they accompanied?
  12. Are there nuclear family members left behind in country of origin?
  13. Are there plans to reunite with family members who stayed behind?

    14. Trauma History

  14. Was there a trauma suffered by patient or family member related to political, social or domestic violence abuse, or sexual abuse?
  15. Was this issue disclosed (to whom, by whom, at what point), or was it avoided? How was it talked about?
  16. Other relevant family events or stresses (e.g. death, loss or separation, chronic illness or disability, imprisonment or threat of imprisonment, harassment) in home or host community.

D. Child's Developmental History

Mother's pregnancy

  1. What were her feelings about being pregnant?
  2. How was the pregnancy received by the couple/family?
  3. How was mother's health?
  4. History of miscarriages or losses?

    5. Birth

  5. Was birth at term?
  6. Was the birth a C/S or vaginal delivery?
  7. Were there complications?
  8. Where did the delivery occur? Who was there?
  9. How did each parent perceive their first contact with their baby?
  10. Was the baby breast or bottle-fed? For how long?
  11. Did mother suffer from post-partum depression?

    12. Infancy and Childhood

  12. Developmental milestones: smiling, sitting, first word, talking, walking, toilet training...
  13. Caretakers: Who cared for the baby?
  14. Was the person whom mother and father wanted caring for baby?
  15. Did they feel anyone was absent from the care-giving network?
  16. Did the baby experience any separations from mother or father?
  17. School and Social History: Child's age entering school?
  18. How did child react to starting school? (Separation anxiety)

E. Social Setting in Canada

Living setting

  1. Who lives in the household?
  2. Which relatives live here?
  3. Does child have special attachment to non-parent relative or non-relative here?

    4. School and social life

  4. How does child function academically and behaviorally at school?
  5. Does s/he have preferred classes, teachers?
  6. Does/he have hobbies, activities, special interests?
  7. Does s/he have friends at school or out of school? From particular ethnic group? A best friend?
  8. Has the child changed schools, did s/he or his/her parents want him/her to change schools? For what reason?

    9. Legal Status:

  9. Did citizenship/immigrant/refugee status change?
  10. How did this affect the family/patient?

    11. Parental work status:

  11. Did either parent lose or change jobs?
  12. Did they experience financial difficulties?
  13. How did this affect the family/patient?

    14. Cultural adjustments for family in Canada

  14. Would child rearing/childhood be different if child were being raised in culture/country of origin (e.g. approaches to feeding/breastfeeding, post-natal support by family, rites de passage for mother and/or baby, pattern of caretaking)
  15. Problems or conflicts with:

_ parental roles

_ authority figures involved in child's upbringing - extended family

_ routines

_ involvement with sibling

_ involvement with peers

_ social activities

F. Cultural Identity in Canada

Language

  1. Mother Tongue
  2. Language spoken with parents
  3. Language spoken between parents
  4. Language spoken at school
  5. Did language spoken at home change when child started school?
  6. How was this decision made?
  7. Language spoken at work
  8. Language spoken in health care settings

    Cultural reference group(s)

  9. Ethnocultural and religious groups with which patient and parents self-identifies
  10. Other ethnocultural background patient or parents do not explicitly identify with
  11. Father's ethnocultural and religious background
  12. Mother's ethnocultural and religious background

    Involvement with culture of origin

  13. Contact with family or friends in country of origin
  14. Involvement with community organizations
  15. Does child attend a group with peers of his culture of origin (e.g. religious school, language school, other academic or leisure setting)?
  16. Does child have culture of origin friends?
  17. Does child socialize with extended family members?
  18. What is child's perception of his culture of origin?
  19. How parents and child interpret child's involvement with friends/ activities? Do they agree?

    Involvement with host culture

  20. Does child attend a group with peers from host culture (e.g. school, religion, leisure)?
  21. Does child have host culture friends?
  22. What is child's perception of host culture? Has s/he experienced racism?
  23. What are child's/family's attitudes about dating?
  24. How parents and child interpret child's involvement with friends/ activities? Do they agree?

G. Psychosocial environment and levels of functioning

Social stressors

  1. What does patient/family feel is the worst social stressor? (e.g. political situation in country of origin, refugee status etc.)
  2. Taking into account cultural norms and social and family structure, what unique stressors can the clinician identify?

    3. Social support

  3. What are the most important past and current sources of support (internalized or externalized) for the individual/family?

    4. Levels of functioning and disability

  4. At home, in extended family
  5. community of origin, host community
  6. at work, with peers, at school

V. Course of Treatment

Narrative of treatment, as described by clinician. [Please refer to checklist of

a) therapeutic modalities and b) systemic issues, as outlined below.]

1) Please check all therapeutic modalities used:

Medical (Referral)

__ GP

__ Specialist?

Psychiatric Intervention

__ pharmacotherapy

__ psychotherapy ( individual, group, family, play therapy, art therapy, other)

__ Was an interpreter involved?

__ Was a time frame given in advance (e.g. short or long term)?

Religious

__ internal (e.g. prayer, home shrine)

__ institutional

Legal

__ provision of psychological expertise

__ liaison with lawyer

__ provision of supportive letter

__ appearance at court

Community

__ Referral to key member of person's cultural community

__ Referral to community aid organizations

__ Reinsertion into community of origin, host community, other communities

School

__ Was child placed in a special class?

__ Remain in regular class with resource help?

__ Other resources provided by school?

__ Did consultant liaise with principal? Teacher?

What was discussed?

How was this received?

Traditional

Where was treatment sought: country of origin, host country, transnational network?

Was traditional healing provided by person's culture of origin or another cultural tradition?

2) Systemic Issues

In following section, focus on:

  • Actors Involved (who was involved, who proposed what, role of interpreter)
  • Interaction of modalities (separation, integration and/or overlap,
  • areas of conflict, successful collaboration or synergy)
  • Evolution of relationship among actors involved: split, integration or transformation
  • Evolution of association among modalities
  1. Who from the family was seen, were they seen alone or separately?
  2. Were other team members involved with patient or family? Why?
  3. Problem listÌý: what were the main problems which needed to be worked on, as decided during evaluation or during process of therapyÌý?
  4. What types of therapy were used to approach these problems? Did any one form of therapy prevail (art, games)? WhyÌý?
  5. How did the child's behavior change throughout treatment (with therapist, with parents, at school, etc.?)
  6. Key dates/turning points in treatment
  7. Key obstacles encountered? Were any resources/services wished for that were missing?
  8. Was there mediation/interaction with other institutions? Please recount the process of mediation, how did it evolve and what were the problems or alliances with other institutions (e.g. DYP, SARIMM, refugee board), and their different actors?

VI. Outcome Questions

  1. Is the therapy still on-going, was it ended, or abandoned (explain how, why: transgression, incomprehension, conflicts)? How long did therapy last (or, if still on-going, how long has it been and how much longer is it envisaged).
  2. What were the hoped for/expected results of the therapy: for patient, for family, for clinician?
  3. What have the actual results been? What have been positive and negative effects of therapy? How was the therapy linked to the outcome?
  4. In terms of the outcome of therapy, who were the most important actors, and what were most important actions which led to results? What elements related to culture were important in the therapy, what were they and how were they addressed?
  5. What does the outcome mean for the child, the family, the school, the community? Has this outcome changed or modified his/her/their lives?
  6. Did other problems surface during the therapy (i.e. not directly related to the original problem)? What are the current outcomes for those problems?
  7. What is the child's functional level of the child now: at home, at school, in the community? What is the predicted sequence for the child and his/her family?
  8. What is/has been the time frame for the development of predicted outcomes?
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