Cultural Formulation According to Dr. Francis G. Lu, MD

Dr. Francis G. Lu, M.D. On May 7, 2013, I was lucky to catch a great Grand Rounds presentation from Dr. Francis G. Lu, MD who is the Luke & Grace Kim Endowed Professor in Cultural Psychiatry at University of California Davis. One of our residents, Dr. Nicole S. Castillo, MD introduced him because she is sponsoring his talk in her capacity as APA/SAMHSA Minority Fellow. You can read more about the Fellowship at link, PsychiatryOnline | Psychiatric News | News Article Minority Fellowship’s Good Works and peek at this great video as well,

Anyway, the title of Dr. Lu’s presentation was “Bringing Culture into the Clinical Encounter: DSM-IVTR Outline for Cultural Formulation”. According to Dr. Lu, a culturally competent organization or individual involved in patient care:

  • Values diversity.
  • Assesses themselves first (check your own pulse).
  • Manages the dynamics of difference by asking questions and not assuming, listening for understanding first, then seeks to be understood.
  • Acquires and institutionalizes cultural knowledge (do your homework).
  • Adapts to diversity and the cultural contexts of the patients they serve.

Learning to be culturally competent means being humble, paying attention to the power differential between patient and caregiver that arises in each encounter, and being responsive to cultural differences by acting with integrity when it’s time to diagnose and treat.

There’s a raft of reports and books out there showing the rationale for treating each other with respect when it comes to cultural differences (not just differences racial and ethnic difference, but gender and sexual preferences, spirituality and more). The literature includes but is not limited to the Institute of Medicine Crossing the Quality Chasm 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century – Institute of Medicine and to the book “Disparities in Psychiatric Care” edited by Pedro Ruiz and Annelle Primm, deputy medical director and head of the APA’s Office of Minority and National Affairs, Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives by Annelle Primm | 9780781796392 | Hardcover | Barnes & Noble.

Clear standards have been developed for culturally appropriate services which have been developed by the Office of Minority Health, U.S. Department of Health and Human Services in 2001, called the National Standards for Culturally and Linguistically Appropriate Services (CLAS, National Standards on Culturally and Linguistically Appropriate Services (CLAS) – The Office of Minority Health – OMH). Web training is available at

The DSM-IV-TR outline for cultural formulation follows:

A. Cultural identity of the individual

B. Cultural explanations of the individual’s illness

C. Cultural factors related to psychosocial environment and levels of functioning

D. Cultural elements of the relationship between the individual and the clinician

E. Overall cultural assessment for diagnosis and care

This outline was the subject of the 2002 DVD “The Culture of Emotions”, an hour long program with over 20 multicultural experts commenting on the five sections of the outline, and about which I posted, Cultural Competence Begins with Humility and Respect – The Practical Psychosomaticist.

The DSM-5 is out this month and so the Culture-Bound Syndromes will be replaced by a more nuanced section the cultural concepts of distress including idioms of distress, explanatory models for illness, and treatment pathways. I’ve pre-ordered the DSM-5 and will be eager to compare it with Dr. Allen Frances’ answer to it, “Essentials of Psychiatric Diagnosis” (Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5) regarding cultural formulations.

Dr. Lu didn’t just talk about pathology; he emphasized the importance of identifying culturally related strengths including a sense of humor (what have I been telling you?), bilingual and multilingual skills, pride in one’s culture, culture-specific beliefs that help you cope, and…wisdom from experience.

So of course, when Dr. Lu concluded his presentation, a colleague sitting next to me asked me the million dollar question, “How are you going to change your clinical practice based on this presentation?” I’m a psychiatric consultant. I run all over an 800 bed hospital and I confess my immediate reply was “I’m not sure yet”. Frankly, I was mentally sifting through the best open-ended questions I could efficiently integrate into an already complex interview algorithm without making the process like an interrogation.

I bounced the query off one of the residents, all of whom are much smarter than I am. She just opens the visit by acknowledging cultural differences (or even similarities that could risk making inaccurate assumptions) and asks what kind of help the patient would like.

Gee, I wish I’d thought of that.

Dr. Lu’s Recommended Reading List and Web-based Resources:

Hays P. Addressing Cultural Complexities in Practice, 2nd ed. Washington D.C. American Psychological Assoc Press, 2007

Josephson A. and Peteet J (eds). Handbook of Spirituality and World Views in Clinical Practice. Washington D.C. APPI, 2004

McGoldrick M et al (eds). Ethnicity and Family Therapy, 3rd ed. New York: Guilford Press, 2005

Griffith, J and Griffith, M. Encountering the Sacred in Psychotherapy: How to Talk with People about their Spiritual Lives, 2001

Griffith, J. Religion that Heals, Religion that Harms: A Guide to Clinical Practice. 2010

EthnoMed (University of Washington Harborview Medical Center)

The Provider’s Guide to Quality and Culture-Outstanding web-based training on clinical cultural competence

Resources for Cross Cultural Health Care

Health Resources and Services Administration

National Health Law Program on language access (under menu heading “Publications”)

The California Endowment

Spiritual Competency Resource Center