Cultural formulation can help clinicians understand how culture shapes distress, help-seeking and experiences of illness. However, when cultural knowledge replaces curiosity about the individual, it can become the very stereotyping it is intended to prevent.
When an explanation arrives before an assessment
Growing up in India, taking a child to mental health services was not something many families around me would have considered. Distress that left no visible mark was often something to overcome, not something a clinic addressed.
So, when I struggled with mathematics, the explanation arrived before any assessment did: I was not trying hard enough. More effort would fix the numbers. The possibility of dyslexia and dyscalculia, eventually named when I was fourteen, went unconsidered because the world around me had already settled on its answer: effort and character.
I was not assessed. I was presumed.
Whether that was understanding or stereotyping turned on one thing: did the explanation open a question, or close one?
“I was not assessed. I was presumed.”
What cultural formulation is meant to do
This is the hinge of the problem. Cultural formulation is meant to slow that certainty down. It asks the clinician to treat culture as something to be explored with the person, rather than something already known about them.
Frameworks such as the Cultural Formulation Interview emphasise how people make sense of their own difficulties, rather than relying only on biomedical interpretation1.
Used well, culture becomes a source of better questions. It also guards against what Arthur Kleinman called the category fallacy: applying diagnostic categories across cultural settings without first considering whether they have the same meaning or validity within that context2.
When cultural knowledge becomes certainty
Stereotyping begins when culture stops being a question and becomes an answer. It occurs when migration, religion, family expectations or community beliefs are treated as relevant before the person has made them so.
It does not happen because culture is considered. It happens because culture is presumed.
A deeper problem is that cultural knowledge can feel like certainty. Clinicians are rightly encouraged to develop cultural competence, but expertise can make it tempting to think we understand before we have asked enough.
Kleinman and Benson warned that cultural competence can reduce culture to a technical skill or a set of facts about particular groups. This risks replacing an individual conversation with assumptions based on identity or background3.
That risk may be sharpened by the ordinary pressures of clinical work. It has been argued that when clinicians work under high cognitive load, they rely more heavily on group-level assumptions and less on effortful, individual reasoning4. When time is short and caseloads are heavy, a group-level explanation is quicker than the slower work of understanding one person. It can also feel reassuringly professional.
Stereotyping is therefore often less about lacking cultural knowledge than about allowing knowledge to take the place of attention to the individual.
“Stereotyping does not happen because culture is considered. It happens because culture is presumed.”
Why culture is not one thing
Culture is rarely one thing. People live within overlapping worlds shaped by age, gender, class, religion, education, migration, family and personal history.
Two people from the same background may hold entirely different beliefs about mental health. They may understand distress differently, seek help in different ways or place different levels of importance on family and community views.
Reducing someone to their country of origin, religion or ethnicity flattens this complexity. It also risks repeating the very bias that cultural formulation is intended to challenge.
Cultural knowledge may offer useful context, but it cannot tell us what an experience means to one particular person.
What this means for clinical practice
The answer is not to pretend culture does not matter. That, too, can become a form of bias.
Instead, cultural knowledge should be held as a hypothesis rather than treated as a conclusion. The person’s own understanding of their experiences should remain central5.
This requires clinicians to pause and consider several questions. Have I asked this person what culture means within their own life? Am I treating their background as one possible influence, or as the explanation for their difficulties? What assumptions might I be bringing into the conversation?
In child and adolescent mental health, these questions carry particular weight. A young person’s difficulties may reach the clinician through parents, teachers and other adults, who may each bring different cultural expectations about what counts as distress and what counts as character.
These questions do not require clinicians to abandon cultural knowledge. They require us to use it with humility. Cultural formulation should not be a method for categorising people. It should be a discipline of remaining curious about a particular person.
“Cultural knowledge should be held as a hypothesis, not treated as a conclusion.”
References
- Lewis-Fernández R, Aggarwal NK, Bäärnhielm S, Rohlof H, Kirmayer LJ, Weiss MG, Jadhav S, Hinton L, Alarcón RD, Bhugra D, Groen S, van Dijk R, Qureshi A, Collazos F, Rousseau C, Caballero L, Ramos M, Lu F. Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry. 2014 Summer;77(2):130-54. doi: 10.1521/psyc.2014.77.2.130. PMID: 24865197; PMCID: PMC4331051.
- Kleinman A. Anthropology and psychiatry. The role of culture in cross-cultural research on illness. Br J Psychiatry. 1987 Oct;151:447-54. doi: 10.1192/bjp.151.4.447. PMID: 3447661.
- Kleinman A, Benson P. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med. 2006 Oct;3(10):e294. doi: 10.1371/journal.pmed.0030294. PMID: 17076546; PMCID: PMC1621088.
- Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making. Med Decis Making. 2010 Mar-Apr;30(2):246-57. doi: 10.1177/0272989X09341751. Epub 2009 Sep 2. PMID: 19726783; PMCID: PMC3988900.
- Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978 Feb;88(2):251-8. doi: 10.7326/0003-4819-88-2-251. PMID: 626456.
Conflicts of Interest
None declared.