 Print, complete, and score the following scales. .docx

Print, complete, and score the following scales. Do not
read how to score a scale until after you have completed it.
1. Stressed Out
2. Susceptibility to Stress (SUS)
3. Response to Stress Scale
4. Are you a Type A or Type B?
5. Coping with Stress
6. Multidimensional Health Locus of Control
7. Locus of Control
8. Life Orientation Test
Identify at Least 5 of Your Personal Stressors and 5
Daily Hassles
Using the information gathered in A and B, write a 3-5
page self-reflection paper that includes the following sections:
. Discuss your scores on each of the above scales and write a
couple of brief statements about what that score means for you.
Were you surprised by the score(s)? Did the results of the scales
resonate with your perception of your stress level?
Incorporating information from your text and other academic
sources, provide a summary of your stressors and life hassles.
3. Incorporating information from your text and other academic
sources, provide a summary of what you might do to reduce
your stress.
4. Discuss the issue of personal stress as it relates to
psychological well-being. Relate your own results and thoughts
about your experience with these scales to the information

provided in the text and other academic sources (journal
articles, books, .gov, .edu, or .org websites)
PERSPECTIVE
published: 25 February 2022
doi: 10.3389/fpsyt.2022.846244
Frontiers in Psychiatry | www.frontiersin.org 1 February 2022 |
Volume 13 | Article 846244
Edited by:
Kairi Kõlves,
Griffith University, Australia
Reviewed by:
Jacinta Hawgood,
Griffith University, Australia
Jennifer Muehlenkamp,
University of Wisconsin–Eau Claire,
United States
*Correspondence:
M. David Rudd
[email protected]

Specialty section:
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychiatry
Received: 30 December 2021
Accepted: 02 February 2022
Published: 25 February 2022
Citation:
Rudd MD and Bryan CJ (2022)
Finding Effective and Efficient Ways to
Integrate Research Advances Into the
Clinical Suicide Risk Assessment
Interview.
Front. Psychiatry 13:846244.
doi: 10.3389/fpsyt.2022.846244
Finding Effective and Efficient Ways
to Integrate Research Advances Into
the Clinical Suicide Risk Assessment
Interview

M. David Rudd 1* and Craig J. Bryan 2
1Department of Psychology, University of Memphis, Memphis,
TN, United States, 2Department of Psychiatry and Behavioral
Science, The Ohio State University Wexner Medical Center,
Columbus, OH, United States
Research in clinical suicidology continues to rapidly expand,
much of it with implications
for day-to-day clinical practice. Clinicians routinely wrestle
with how best to integrate
recent advances into practice and how to do so in efficient and
effective fashion. This
article identifies five critical domains of recent research
findings and offers examples
of simple questions that can easily be integrated into a
clinician’s existing suicide risk
assessment interview and related protocol helping inform the
risk formulation process.
Keywords: suicide risk assessment, clinical interview, recent
advances, efficiency, effectiveness
INTRODUCTION
The last several decades have witnessed a sharp, positive
trajectory in suicide-related research,
much of it with direct and important implications for day-to-day
clinical practice (1). In particular,

five identifiable domains of research are of importance for
practicing clinicians, including recent
work demonstrating: (a) the limited predictive value of
traditional suicide risk scales (e.g., the
Columbia Suicide Severity Rating Scale, C-SSRS) in real-world
healthcare settings (2, 3), (b) the
temporal dynamics and natural variability of suicidal ideation
and motivation to die across clinical
and non-clinical populations [e.g., (4–7)], (c) the importance of
assessing constructs other than
suicidal ideation that are convincingly linked to enduring risk
or chronic vulnerability for suicide
[e.g., (8–10)], (d) the importance of understanding and
assessing the potential for poor individual
adherence and cooperation with clinical care (8), and (e) the
elegant utility of patients’ expressed
wish to live and wish to die, coupled with reasons for living and
reasons for dying (11–13).
Regardless of the clinician’s preferred theoretical perspective or
approach, findings across all five
of these domains can easily and efficiently be integrated into
the suicide risk assessment interview,
with straightforward questions that carry very little time-burden
for the clinician and/or patient,
while potentially capturing data essential to efforts to
accurately understand, assess and respond to
suicide risk.
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full
Rudd and Bryan Clinical Application of Suicide Research
Clinicians routinely struggle with how best to integrate a
range of formal suicide risk assessment tools into day-to-day
practice. Although suicide risk assessment screening tools are
almost uniformly recommended, their limited predictive value
is readily recognized and acknowledged [e.g., (14–16)]. We are
not arguing against the use of formal suicide risk screening and
assessment tools, as they serve an important and essential role
in
the overall risk assessment process. However, the problem of
poor
predictive value is compounded by clinicians having to juggle
significant time demands, coupled with the challenge of finding
effective ways to create a compassionate and caring assessment
environment that will increase the likelihood of accurate self-
report, increase self-disclosure during the clinical interview,
and
help develop a strong therapeutic alliance (17). There are a
broad
range of reasons why patients might be hesitant to accurately
self-
disclose on both assessment instruments and during the clinical
interview, such as shame, the need for control/autonomy,
limited
emotional self-awareness/understanding, and disruption created

by current symptoms [e.g., (18)]. All too often, the net result
is that clinicians might overlook that many of these empirically
supported constructs can be integrated into the clinical
interview
in simple and straightforward fashion, adding only a fewminutes
to the clinical interview.
Below are a few suggestions on how to incorporate some of
these recent research advances into a standard clinical suicide
risk assessment interview in a brief, but targeted manner.
These suggestions are by no means intended to represent
the entirety of a comprehensive suicide risk assessment [e.g.,
(15, 19)]; rather, they are only examples of simple strategies
that can be used to supplement a clinician’s existing suicide
risk assessment interview and clinical decision-making process.
Critical risk factors and domains assessed by existing tools,
instruments and approaches are essential to an effective and
comprehensive assessment of suicide risk (16); the material
presented here should simply be viewed as supplemental
in nature.
JUDICIOUS USE OF SUICIDE RISK
SCREENING TOOLS
Suicide risk screening and assessment with a standardized
instrument or scale is a recommended standard of care element
in outpatient mental health, inpatient psychiatric, and
emergency
department settings (National Action Alliance for Suicide
Prevention, 2018). Screening and assessment for suicidal
ideation
and behaviors in particular are recommended during the first
clinical encounter (e.g., intake) and regularly during subsequent
contacts. Screening tools and standard assessment instruments
are only a starting point and one piece of information in a

comprehensive suicide risk assessment process. Clinical
decisions
should not be made based solely on the scores obtained from
these instruments, however, as considerable evidence shows
that suicide risk screening tools have very poor accuracy and
predictive value (2, 3). The accuracy of standardized
instruments
is reduced in part by the unwillingness (or even inability)
of some individuals to reveal risk through direct and specific
questioning (15), along with the observed temporal dynamics
of suicidal thinking (4), a phenomenon that existing assessment
tools are yet to meaningfully capture and measure. Clinical
decisions should instead be made based on the integration of
multiple data points from multiple sources (e.g., behavioral
observations), which can help contextualize these scores, with
the clinical interview arguably at the nexus. Expanding the
clinician’s available assessment toolkit with targeted clinical
interview questions based on recent research advances will
hopefully generate additional data to help inform and improve
risk formulation and related clinical decision making.
THE DYNAMIC NATURE OF SUICIDAL
IDEATION
Standardized suicide risk instruments are ill-suited to assess
the natural temporal dynamics of suicidal thinking. Suicidal
ideation and motivation to die ebbs and flows, sometimes
very rapidly. If the patient denies active suicidal thinking, the
clinician should consider and explore the possibility of cycling
in suicidal thinking and motivation to die, which has been
linked with increased risk for suicidal behavior (5, 6, 20). More
specifically, some individuals may accurately deny active
suicidal
thoughts and related intent to die, but also experience very

rapid onset of specific suicidal thoughts and strong motivation
to die, often with little forewarning. Recognizing such cycling
is important to an accurate understanding of individual suicide
risk. Potential shifts and cycling in suicidal thinking and
desire to die for some individuals can be captured with a few
simple questions:
Some people find that their suicidal thoughts and desire to die
come and go, changing rapidly from minute to minute, hour to
hour, or day to day? Does this describe you? Can you describe
any pattern(s) you’ve noticed in your suicidal thinking? What is
an average day or week like for you?
Since you don’t report any active suicidal thoughts, if
agreeable, let’s focus on the last time you thought about suicide
and felt motivated to die. When was the last time you thought
about suicide? Let’s focus on that episode to see if there’s any
identifiable pattern to how your thoughts about suicide and
motivation to die come and go.
ASSESSING CONSTRUCTS OTHER THAN
SUICIDAL IDEATION
Recent findings regarding the limited predictive value of
traditional suicide risk assessment tools reinforces the need to
assess other markers of enduring suicide risk that are strongly
correlated with the emergence of suicidal behavior but are
distinct from suicidal ideation and planning. For example,
perceived burdensomeness (9), acquired capability (10), and
identity-based hopelessness (21) have garnered considerable
empirical evidence as useful indicators of heightened risk
states. As with efforts to understand temporal dynamics,
these constructs can be assessed with simple, straightforward
questions. They also have the potential advantage of being

indirect indicators of risk and create an opportunity to identify
significant risk even when direct questions prove ineffective or
active suicidal thoughts are denied. Similarly, entities such as
the
Royal Australian and New Zealand College of Psychiatrists (22)
have emphasized the importance of a comprehensive approach
to suicide risk assessment that considers variables identified
by the individual as uniquely contributing to their suicide
risk (e.g., homelessness, bullying, rejection). As summarized
at the end of this article, these unique indicators can be
cogently captured by an examination of reasons for dying
and reasons for living, to include asking the patient to rate
the current intensity of motivation to die attached to each
specific reason.
The six-item Brief Suicide Cognitions Scale [B-
SCS (21)], for instance, can be translated into clinical
interview questions across three domains important to
recognizing the presence of identity-based hopelessness:
unlovability, unbearability, and unsolvability. Although
the formal scale includes only six items, clinicians can

translate findings to interview questions that assess
each domain:
• Do you ever feel completely unworthy of love or that there is
nothing redeeming about you?
• Do you ever feel like your emotional pain is unbearable?
• Do you ever feel like your problems are unsolvable?
Perceived burdensomeness (23) can be similarly assessed with
a simple question:
• Do you ever feel like a burden on your loved ones, or that
they’d be better off if you were dead?
Unlike unlovability, unbearability, unsolvability and perceived
burdensomeness, acquired capability to die is an observed
variable that can be inferred from past behavior, prior trauma,
abuse, and/or repeated exposure to death and violence:
• Have you ever done things to harm yourself, with no intention
of dying, like cutting, burning, or hitting?
• As we’ve discussed, personal history is important to
understanding how each of us experience the world around us.
Have you had any experiences you would consider traumatic,
particularly those involving exposure to violence or death?
• Some people experience events during the course of their work
thatmight contribute to thoughts of suicide and the capacity to
take their own life, such as exposure to violence and/or death.
Has this been the case for you?
When factors suggesting the potential for elevated capability
for suicide are identified, clinicians should integrate this

information into their overall clinical assessment. Again, this
is an observation that needs to be noted and factored
into subsequent risk formulation. Elevated acquired capability
suggests that suicidal episodes may have a lower threshold
for activation, occur more often, potentially last for longer
periods of time, and subsequent suicidal behaviors may be more
lethal (23).
Firearm availability is another important element of elevated
capability for suicide. Firearms are muchmore likely to be fatal
as
compared to other suicide attempt methods (24–30). Clinicians
should therefore ask about firearm access, even with patients
whose suicidal thinking involves other (non-firearm) methods.
Additionally, clinicians should always inquire about access to
multiple methods:
Even though you haven’t mentioned a firearm, it’s important
to know if you own or have access to one. Do you own or have
access to a firearm?
We have found that most individuals considering suicide
think about more than one method. What other methods have
you considered when having thoughts about killing yourself?
TREATMENT HESITANCY AND
NON-ADHERENCE WITH CLINICAL CARE
RECOMMENDATIONS
In a recent comprehensive review of randomized clinical
trials targeting reductions in suicidal behavior, Rudd and

Munoz-Perez (8) identified commonalties of treatments that
work, with the recognition that assessing and responding to
individual patient hesitancy and non-adherence with clinical
care recommendations was a critical variable, along with
the importance of having a clearly articulated adherence
protocol. Non-adherence is a function of a broad range of
variables ranging from straightforward barriers like a lack
of transportation to more complex individual ones such as
ambivalence about treatment, disruption created by active
symptoms, and limited self-management skills necessary for
full treatment engagement. Translating this finding into the
clinical interview cuts across two variables. First, it is
important
for the clinician to recognize that patients who have made
multiple suicide attempts often have reduced capacity for self-
management and adherence due to limited self-regulation skills.
Second, the potential for poor adherence can be assessed with
a simple question every time the clinician makes a specific
intervention request, such as using a crisis response or safety
plan, following through with a means safety plan, practicing
a newly learned skill, or taking their prescribed medication.
This can be accomplished with a simple question following
each request:
• It is not uncommon for people to feel uncomfortable about or
struggle developing new skills. Accordingly, I’d like to better
understand how you’re feeling about doing the task we just
discussed. How likely are you to do what we just discussed on
a 1–10 scale, with 1 being you absolutely won’t and 10 being
you absolutely will?
This question not only can be integrated into the clinical
interview, but also included as part of the overall adherence
protocol within the treatment plan, because it allows the
clinician
an opportunity to proactively target, understand, anticipate,

and respond to potential problems. In terms of the overall
adherence protocol, the question also creates a unique window
of opportunity for addressing low motivation and/or barriers
to treatment engagement. Under these circumstances, clinicians
can collaboratively engage patients in a conversation aimed at
modifying or altering the recommended treatment strategy in
a way that may increase motivation, adherence to clinical care
recommendations, and eventual success in care. For example,
the
clinician might ask the following if a patient provides a low
rating
to the question above about likely strategy use:
• Your rating indicates it’s likely that you won’t be able to do
what we just discussed. Can you help me better understand
what might get in the way of doing the task?
Each identified barrier can then be discussed and targeted in a
proactive fashion:
• What can we change about the task to increase the likelihood
of you doing this? What steps can we take to move your rating
to a 6 or above indicating it’s more likely than not you’ll be
successful in completing the task? If needed, we can practice
the skill or role play the strategy a few more times to increase

your level of confidence before our time is up today.
ASSESSING THE WISH TO LIVE AND THE
WISH TO DIE
Finally, recent findings on the clinical utility of a patient’s
expressed wish to live and wish to die, coupled with reasons
for living and reasons for dying (11–13), can be translated
to a few simple questions that can be used routinely during
assessment and ongoing treatment. More specifically, they can
be assessed and tracked separately with simple self-ratings,
providing additional insight into how the desire to die and
desire
to live are changing over time, and how these shifts correspond
with the temporal dynamics of the individual’s suicidal
ideation:
• Can you rate your current wish to die on a scale of 1–10, 1
being no wish to die and 10 being a very strong wish to die?
Let’s talk about your reasons for dying. What are your reasons
for dying? Why do you believe you need to kill yourself?
• Can you rate your current wish to live on a scale of 1–10, 1
being no wish to live and 10 being a very strong wish to live?
Let’s talk about your reasons for living. What are your reasons
for living or for not killing yourself?
Identifying and discussing reasons for living also provides a
useful platform for identifying and implementing interventions
that can enhance cognitive flexibility and undermine the
negative
cognitive bias that characterizes suicidal states (12). Recent
research further suggests that including a patient’s reasons for
living as a component of their crisis response or safety plan
may lead to faster reductions in suicidal ideation, promote

protective psychological states like hope and optimism, and
support effective emotion regulation (31–33). As Brown et al.
(34) noted, identifying a suicidal individuals’ reasons for dying
and reasons for living allows the clinician a mechanism to
translate their ambivalence in concrete fashion, essentially a
weighted value, coupled with the ability to actively engage
their expressed ambivalence clinically, strategically intervene to
move it in the direction of living (i.e., adding to the reasons
for living list), and subsequently track it over the course of
clinical care.
IMPROVING RISK FORMULATION
As mentioned at the outset, this article is not intended as a
comprehensive approach to the suicide risk assessment clinical
interview. Rather, the hope is threefold. First, to demonstrate
that many recent advances can be translated in simple and
efficient ways into the clinical interview to assess suicide risk.
Second, that the questions can serve as a critical data source,
supplementing information provided from standard assessment
and screening tools, along with other resources. And third,
that this approach provides an opportunity to humanize the
assessment process, empowering the patient’s voice, and help
build a stronger therapeutic alliance essential to the successful
provision of clinical care (17).
Of particular importance to the risk formulation process is
the recognition and subsequent resolution of observed clinical
discrepancies. These questions provide potentially critical self-
report data to consider alongside standard screening and
assessment tools. Data derived from these questions can be
used strategically to explore potential areas of discrepancy
between what a suicidal individual reports on an assessment
tool and what they report during clinical interview. More
important, though, than recognizing the discrepancy in reports,

is allowing the suicidal individual the opportunity to reconcile
and explain the discrepancy. Again, this can be accomplished
with a few simple questions and geared specifically to the area
of discrepancy:
• I noticed on one of the forms you completed earlier you
endorsed an item indicating you had specific thoughts about
how to kill yourself. Earlier you mentioned not having access
to a method right now. I want to make sure we’re on the
same page and I accurately understand how you’re doing.
What did you do with the method you were thinking about
when you completed the form? What other methods have you
thought about?
• I noticed on one of the forms you completed earlier you
mentioned having frequent thoughts about suicide. You
reported not having thoughts of killing yourself now. Can you
help me better understand how your suicidal thoughts come
and go? Earlier we discussed the possibility of a pattern or
cycling of your suicidal thoughts. Do you think that’s what
might be happening?
CONCLUSION
As the volume of clinical research continues to grow, clinicians
appropriately struggle with not only how best to keep pace
with an ever-expanding field, but also how to interpret
findings, integrate them into the risk assessment process, and
do so in a manner that recognizes that clinical practice has
realistic time constraints. The goal is to find ways to translate
research advances into clinical practice in efficient and
effective

fashion. The suggestions offered above provide examples of
how some of those scientific advances in suicide research can
be integrated into day-to-day clinical practice in a simple,
straightforward fashion.
DATA AVAILABILITY STATEMENT
The original contributions presented in the
study are included in the article/supplementary
material, further inquiries can be directed to the
corresponding author/s.
AUTHOR CONTRIBUTIONS
MR and CB were involved in the conceptualization,
development, and writing of the current manuscript.
Both authors contributed to the article and approved the
submitted version.
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https://www.frontiersin.org/journals/psychiatry#articlesFinding
Effective and Efficient Ways to Integrate Research Advances
Into the Clinical Suicide Risk Assessment
InterviewIntroductionJudicious Use of Suicide Risk Screening
ToolsThe Dynamic Nature of Suicidal IdeationAssessing
Constructs Other Than Suicidal IdeationTreatment Hesitancy
and Non-Adherence With Clinical Care
RecommendationsAssessing the Wish to Live and the Wish to
DieImproving Risk FormulationConclusionData Availability
StatementAuthor ContributionsReferences
Families in Society: The Journal of Contemporary Social
Services | www.familiesinsociety.org | DOI:
10.1606/1044-3894.3822
©2008 Alliance for Children and Families596
ABSTRACT
Assessment and formulation, the gathering of information about
a client, and the conceptual-
ization of the client or situation are the essential elements that
mark a thoughtful approach to
client care. This process has been shaped over time by changes
in orientations to knowledge, new
theories, new practices, and political and institutional pressures.
Currently, there is an intense
debate concerning the nature of social work practice, especially
the assessment and formulation
process. In this context, we review traditional approaches to
formulation in light of contempo-
rary understandings and trends. We present a model for
formulation that highlights multiple

ways of knowing and includes ecological, cross-cultural,
psychodynamic, systemic, biological,
and spiritual components. Social justice is the value that is
foundational to the process.
PRACTICE APPRoACHES
This is a time when researchers, educators, and prac-
titioners are debating the essence of social work
(Gambrill, 2006; Graybeal, 2007; Sellick, delaney,
& Brownlee, 2002; Witkin & Harrison, 2001). The clinical
practices of assessment and formulation are at the center
of this debate. The form that clinical social work practice
takes in the future will be strongly influenced by the way
that social work educators and practitioners conceptualize
the processes of assessment and formulation. As teachers of
practice, and as practitioners ourselves, we wish to enter the
debate and offer a model of assessment and formulation for
the consideration of educators, students, and practitioners.
The model is comprehensive and multidimensional. It
highlights several knowledge areas considered important
in the process of understanding a client or situation. The
domains that we have selected are not new; they have long
been the ways that social workers think about clients. We
consider it especially important in a time of change to
review traditional practices and reconfigure them in light
of contemporary theories and approaches. The model will
help clinicians hold on to full, rich, and complex under-
standings of clients and clinical work.
In this material we first define what we mean by the
terms assessment and formulation. Then we discuss the
nature of current challenges and show how they emerge

from historical trends in social work. Having explored
current and past themes, we present our model and dem-
onstrate its application with a case example.
Defining Terms—The Language of
Social Work
Work with a client begins with eliciting information con-
sidered relevant to the issue with which the client presents
Assessment and Formulation:
A Contemporary Social Work
Perspective
Ruth G. Dean & Nancy Levitan Poorvu
Dean & Poorvu | Assessment and Formulation: A
Contemporary Social Work Perspective
597
(mattaini & Kirk, 1991). We refer to this process as the
assessment. We define formulation as a focused, brief
conceptualization of the client or situation, based on the
assessment. It highlights the central issues, offers a ten-
tative understanding of them, and sets the groundwork
of the plan for intervention that follows (madsen, 2007;
Perry, Cooper, & michels, 1987; Ross, 2000). Assess-
ment is an ongoing process that leads to inferences and
hypotheses that contribute to the developing relationship
between worker and client as they reflect on themes and
increase their understanding of an issue or problem (Ger-
maine & Gitterman, 1996). In most models of contem-
porary practice, the way social workers formulate their

cases is developed in collaboration with clients, privileg-
ing their views and supporting their strengths (madsen;
Parton & o’Byrne, 2000).
models for assessment developed in the fields of psy-
chiatry, psychology, and family therapy have made impor-
tant contributions to the ways social workers formulate
their cases. Social workers must be able to speak the
languages of the Diagnostic and Statistical Manual of
Mental Disorders (DSM–IV–TR; American Psychiatric
Association, 2000) and psychodynamic, developmental,
behavioral, and family systems theories, to name a few
current influences. But borrowed understandings leave
out interests essential to social work. our model integrates
multiple perspectives, some of which originated in other
disciplines, within an orientation that is consistent with
the values, theories, practices, and language of social work.
This approach, highlighting multiple ways of knowing, falls
within a constructionist perspective. Forces in social work
representing different views would challenge this choice.
We now consider some of these current challenges.
Current Challenges
Powerful intellectual and political and social forces are
challenging the social work practices of assessment and
formulation. In the academy, two very different orienta-
tions to knowledge have been the source of strong debates
that began in the 1960s with critiques of the ideal of objec-
tive truth and an objective scientific methodology (Irving,
1999; Sellick et al., 2002). These orientations are variously
referred to as modern and postmodern, empiricist and
postempiricist, and realist and constructionist (Iversen,
Gergen, & Fairbanks, 2005). They have powerful impli-
cations for social work education and practice; they also
direct the ways in which assessment and formulation are

conceptualized and enacted.
Those steeped in empiricist models, such as the advo-
cates of evidence-based practice, argue for a research-
based, scientific orientation to assessment and treatment
planning (Gambrill, 2006; o’Hare, 2005; Rosen, 2003).
Scales and assessment instruments may be used to help
name the problem being treated and to offer a baseline
for assessing change (o’Hare). In this model, although
clients’ views are considered, the worker’s expertise and
responsibility for assessment and treatment planning is
stressed (o’Hare).
The postmodern or constructionist orientation empha-
sizes the shifting, evolving, contextual, and fluid aspects
of knowledge, and this orientation questions whether
objectivity is at all possible in selecting the information
that goes into a formulation (dean, 1993; Iversen et al.,
2005; Parton, & o’Byrne, 2005). multiple perspectives are
utilized, based on the belief that all views are partial and
that no single theory or perspective has a monopoly on the
“truth” of a situation. Clients’ understandings and mean-
ings are privileged, and the process of formulation involves
collaboration between workers and clients (madsen, 2007).
In addition to pressures emanating from these ideo-
logical differences, political and institutional changes in
the United States have altered the context in which social
work practice occurs with implications for the assessment
process. The conservative political turn that has gripped
the United States in the past 30 years has led to disman-
tling the safety net established by President Franklin
Roosevelt during the New deal (Krugman, 2007). This
has meant decreased support for social services, tighter
agency budgets, and pressure to limit workers’ hours

to those spent in direct client contact (Barlas, 2006;
Schneider, Hyer, & Luptak, 2000; Stoil, 2001). The man-
agement of care by third-party payers requires medical
(psychiatric) diagnoses. Formulations are often limited
to DSM–IV–TR diagnostic categories, determinations of
risk, problem lists, and the specification of measurable
outcomes (Cohen, 2003; Furman & Langer, 2006; mishne,
2004; Schneider et al., 2000).
In this stressful practice climate, strongly held differ-
ences have emerged among social workers concerning
the priorities of the evaluation process. Some emphasize
measurable behavioral change; some focus on “strengths”;
others focus on culture, context, ecological factors, politi-
cal inequalities, social injustices, intrapsychic phenomena,
and systemic issues. Tensions inherent in these differences
have at times resulted in oversimplified assessments that
represent the views of a single camp. Although most social
workers agree that some form of inquiry and assessment
is needed, what this should consist of is unclear.
We do not wish to take sides in this debate, for each side
has something to contribute to a discussion of assessment
and formulation. Like the empiricists, we see the need
for establishing a baseline formulation of the problem
that will guide the interventions that follow and make
it possible to evaluate outcomes. But, in agreement with
the constructionists, we believe that any view is tentative
Families in society | Volume 89, No. 4
598
and will (and should) dissolve or shift as the work pro-

ceeds. Although we see the necessity for using words and
categories to organize thinking, we also believe, with the
constructionists, that words construct rather than reflect
the ways we see the world. The words we use to construct
a client can be morally evaluative and negatively affect the
ways that others see him or her (Urek, 2005). These words
have serious, damaging effects and forever obscure the
person he or she is. Therefore, we must choose the words
we use in a formulation very carefully, and hold them
lightly, always ready to be changed. We prefer descriptive
to diagnostic terms and, if possible, the use of clients’
words to describe their plights. We support a collaborative
effort in which clients’ views are primary (construction-
ist). But we also see the need for the worker’s expertise
to guide the process (empiricist). Thus, we see the work
of assessment proceeding within the tensions of differ-
ing intellectual traditions. These tensions have existed
throughout the history of the profession.
The History of Assessment and Formulation
in Social Work
From early in its history, social work has struggled to lose
its association with friendly visiting and be recognized
as a profession. In 1917, mary Richmond’s seminal book,
Social Diagnosis, set in motion assessments that involved
investigative studies of clients and their families and,
based on these studies, the development of diagnoses that
defined treatment. Although strongly influenced by the
medical model, Richmond incorporated ideas of commu-
nity context and individual and family strengths into her
view of diagnosis.
Since these early beginnings, changes in the assessment
and formulation process can be divided into three catego-
ries: shifts related to ideological differences, the influence of

new practice models and approaches, and recurrent themes.
In the material that follows we highlight each area.
Conceptual Shifts
Whereas early evaluations employed a linear, cause-and-
effect view of problems, an appreciation for multicausality
gradually emerged (Hollis & Woods, 1981). The need to
collect a large number of facts about a client or situation
was tempered by recognition of the importance of the
meaning that events and situations had for clients. A focus
on relationships and the client’s relational history was
prominent early on (Graybeal, 2007; Perlman, 1979); in
the past 20 years, there has been more interest in problems,
solutions, and behavior (de Shazar, 1985; madsen, 2007).
Interest in developing a scientific base for the profession
moved social work beyond the earliest forms of assess-
ment, which were based on determinations of worthiness
(Brill & Taler, 1990; Canda & Furman, 1999; Richmond,
1917). However, there have been strong differences as to the
ways that science is defined, along with notions of how sci-
entific interests should affect the process of assessment and
treatment (Graybeal, 2007; Witkin & Harrison, 2001).
Assessments became more sensitive to the impact of
race, culture and ethnicity, gender, and sexual orientation
(Boyd-Franklin, 1989; Laird & Green, 1996; mcGoldrick,
1998; Panos & Panos, 2000; Pinderhughes, 1989). The
impact of immigration, whether recent or in an earlier
generation, has become a more current focus, along with
greater understanding of the strain of acculturation and
of intergenerational conflicts in immigrant families (mir-
kin, 1998; mock, 1998).
Understanding of the role of social injustices and

oppression as causal factors in people’s troubles and the
need to assess their impact has always been part of social
work thinking. Issues of reform and community solidar-
ity raised by Reynolds (1973) in the 1930s evolved into
later models of empowerment that focused assessments
on the strengths of individuals and the resources in their
communities (Lee, 2001; Reynolds; Weinberg, 2006).
Influence of New Theories, Models,
and Approaches
As new theories, models, and approaches emerged in the
human sciences, they were taken up by social work and
were influential in assessment and formulation. Psycho-
analytic theory, as it took hold in the United States in the
1940s, turned social workers’ attention to intrapsychic
causes and personal history (Hollis & Woods, 1981).
This psychoanalytic focus was followed in the 1970s by a
wave of family therapies that focused on larger systems,
groups, and family interactions and structures (Brill &
Taler, 1990; minuchin, 1974; Shulman, 1992). The psycho-
dynamic and systemic methods spawned many schools
and therapies, which were readily absorbed and then
discarded by social work programs (H. Goldstein, 2001).
Each new model prioritized something slightly different
in the evaluation and treatment process.
Social work’s basic interest in context, expressed early in
the “person-in-environment” configuration, was broad-
ened with the introduction of the ecological model (Ger-
maine & Gitterman, 1996). Increasingly, there has been a
turn toward a risk and resilience form of ecological model
that allows workers to conceptualize a problem at multiple
levels and consider the internal or external risk and pro-
tective factors (Corcoran & Nichols-Casebolt, 2004).
Recurrent and Expanded Interests

In a reaction to the deterministic and diagnostic direc-
tions of Freudian theory, humanistic concerns with indi-
vidual will and people’s strengths emerged at different
599
historic times, as seen in the Functional School in the
1930s (Robinson, 1930), and the “strengths perspective”
in the 1990s (Saleeby, 2005). Belief in the importance
of focusing on health instead of pathology changed the
direction of assessments (Saleeby, 2005; Weick, 1986).
The biological part of a “biopsychosocial” formulation
was broadened to include considerations of health, fit-
ness, genetic endowments, predispositions, and “normal”
changes associated with life phases, such as aging. The
concept of able-bodiedness reshaped consideration of
physical challenges. New understandings of mind–body
connections led to an awareness of the relationships
between spirituality and religious beliefs to well-being
and the importance of including these areas in assess-
ments (Griffith & Griffith, 2003; Perry, 1998).
Finally, the debate about the relationship of science to
social work practice has been recurring and, at times,
sharp and divisive. It is currently represented by the
evidence-based practice movement (o’Hare, 2005). The
practices of assessment and treatment that this movement
supports collapse models of research and practice, so that
the process of formulation becomes problem analysis
(o’Hare). Problems are rendered in the form of research
questions and then used to search the professional lit-

erature for interventions supported or informed by con-
trolled experiments. Evidence-based practices currently
available are studied in terms of their applicability and
appropriateness in a particular situation and modified as
necessary to the situation at hand. outcomes are defined
operationally and then assessed according to standard-
ized outcome measures (Rosen, 2003).
Ongoing Tensions
Tensions observed in these conflicting approaches have
carried forward in current practice. These include con-
flicts inherent in balancing the profession’s commitment
to strength-based assessment with models or settings that
require diagnosis of illness, deficits, or risks. There are
additional conflicts between a commitment to a collabor-
ative approach with clients and situations that require the
social worker to render an “expert” or diagnostic opinion
(e.g., assessment of suicidality). Finally, there are strong
differences regarding ways to ensure the effectiveness of
social work practice. These ongoing strains are not neces-
sarily resolvable since responses to them emanate from
very different knowledge orientations. We believe they
add to the vitality of the profession.
Components in Social Work Assessments
and Formulations
Social work practice has been shaped by interests and
necessities that fluctuate over time. But the values of the
profession are foundational. They have remained con-
stant, but their meaning has evolved as social work prac-
titioners have become more cognizant of the dimensions
of power, oppression, and difference.
Social Justice Perspective

A primary social work value is the belief that all human
beings should be treated as unique individuals with cer-
tain basic rights including the right to self-determination.
The profession’s commitment to social justice emphasizes
that many peoples’ problems reflect the difficulties of
living in an unjust and oppressive society. These values
are reflected in social work formulations that include the
uniquely individual characteristics that affect a person’s
well-being and the institutional and political dimensions
of people’s problems.
Thus, formulation begins with a social justice perspec-
tive that takes into account the ways in which social forces
and conditions constrain clients’ lives and affect the ways
we see them. These forces include the devastating effects
of poverty and violence along with prejudices enacted in
relation to gender, race, age, class, ability, sexual orienta-
tion, and other differences. A social justice perspective
that is sensitive to power and social inequities also focuses
social workers on their social identities and power in rela-
tion to clients. This sensitivity to differences can make it
less likely that oppression will be unwittingly repeated in
the worker–client relationship.
Ecological Perspective
An ecological perspective emphasizes the dynamic trans-
actions between people and the multiple social systems,
subsystems, and environments in which they participate.
This understanding requires careful observation of the
actual places where clients spend their time (homes,
schools, communities, and streets) to determine if clients’
interactions with their environments are enriching and
supportive, or limiting and destructive. It includes using
structural data that provide a demographic understand-
ing of the resources and challenges of clients’ neighbor-
hoods, with attention to community-based indicators

of well-being (Ung, 2004). An ecological assessment
begins with clients’ assessments of their communities and
includes their creative solutions to community challenges.
An empowerment approach engages diverse resources to
enable clients to find solutions, expand their capacities,
and enhance the possibilities of their communities.
Diversity and Cross-Cultural Sensitivity
Since the 1970s, social work literature has been particu-
larly attentive to the impact of culture, race, and ethnicity
on peoples’ identities (Atkinson, morten, & Sue, 1979;
Boyd-Franklin, 1989; mcGoldrick, Giordano, & Pearce,
600
1996; Pinderhughes, 1989; Staples, 1978; Sue, 1981). Early
clinical approaches to diversity, coming from a modernist
orientation, used more static and essential views of eth-
nicity, culture, and race.
In contemporary practice when a postmodern frame
is used, the changing, evolving, contextual, and interac-
tive nature of identities is stressed (Laird, 1998). Social
workers are encouraged to appreciate the limits of their
knowledge and work from a “not-knowing” and curious
position, one that supports empathic attunement and
learning what it is like to be in another’s shoes (Anderson
& Goolishian, 1992; dean, 2001). Clinicians need to be
aware of the prejudices, attitudes, and distortions they
carry in regard to other groups and to be self-critical and
open to new understandings (Comas-diaz & Jacobsen,
1991; Hamilton-mason, 2004; Perez Foster, 1999). Sensi-

tivity, respectful curiosity, openness, and self-awareness
are the hallmarks of a formulation undertaken from a
cross-cultural perspective.
Systemic Approaches
A systemic perspective focuses specifically on the systems
in a client’s life such as the family, workplace, church, or
community. The art of formulation lies in making a deter-
mination of the size of the client system to be approached
and the necessary scope of the inquiry. The work might be
with a family subsystem, the nuclear family, or members
of the extended family; it might include several families
in the same community who have a mutual interest, or
several community groups (e.g. teenagers, their parents,
and the police). The focal system could change as issues
improve in one area and become apparent in another.
There are a multitude of systemic theories and
approaches to understanding small groups and fami-
lies. The direction of the formulation and clinical work
depends on which theories are used. The field has moved
from a focus on assessing structures (minuchin, 1974) to
understanding interactive processes (Lowe, 2004). more
recently in narrative approaches, attention is being given
to clients’ stories. If a client’s story is problem-saturated,
there is an effort to help the client replace it with stories
of strengths and resilience, often located at the margins of
a client’s awareness (Anderson & Goolishian, 1992; White
& Epston, 1990). Clients and social workers become part-
ners in co-constructing new narratives.
A systemic perspective focuses on external, observable
patterns and processes, as well as articulated stories. To
understand the client’s problem from a psychological per-
spective, the focus turns to intrapsychic phenomena.

Psychological Perspective
A psychodynamic approach posits that life events, situa-
tions, and early relationships are internalized and influ-
ence ongoing behavior (E. Goldstein, 1995; Hollis &
Woods, 1981). There have been many psychodynamic
“schools”; each highlights different aspects of behavior
and development and shapes the lens of the formulation
process accordingly. Some focus on conflict and resolu-
tion; others, on early relational experiences that shape
ongoing behavior; and still others, on self-development
or attachment. All assume that development occurs in
stages—each phase with its own challenges and oppor-
tunities—and that the way that these challenges are
managed affects a person’s ongoing development and
behavior (Erikson, 1950; Perry et al., 1987). Individual
responses are seen as adaptive and as representing the
best possibility for the person at the time they occur, even
if they become maladaptive later in life. The relationship
between the social worker and client is considered an
additional source of insight regarding the client’s rela-
tional style and patterns.
In this discussion of factors to be considered in formu-
lation we have moved from a broad view of political and
institutional forces to a consideration of neighborhood
environments, family systems, and individual psychology.
At the individual level, two additional aspects of human
functioning to consider are biology and spirituality.
Biological Perspective
The biological component of a biopsychosocial formula-
tion has gained importance, with genetic factors receiv-
ing particular attention at present. Patterns of substance
abuse and family history of mental illness are included in
a biological assessment, along with indicators of well-being or

illness (Bisman, 2001). Cultural beliefs about health, disease,
and healing need to be understood; it is important that West-
ern biases not be imposed on clients from diverse cultures
(Panos & Panos, 2000). Past and present sexual behavior and
attitudes, as well as sexual dysfunction, would be appropriate
subjects for a formulation if relevant to the issues for which
the client is seeking help.
Assessments of persons with disabilities need to dis-
tinguish between impairment, the “physical, sensory,
cognitive, or systemic condition that directly imposes a
reduction in certain functions,” and disability, “those bar-
riers and reductions in function imposed by the physical
and psychosocial environment” (olkin, 1999, p. 89). The
locus of impairment is in the person whereas the locus of
disability is in the sociopolitical environment (olkin).
Spiritual Perspective
Clinicians have not always explored the spiritual compo-
nent in clients’ lives (Gotterer, 2001; Thayne, 1998). Yet
the lack of assessment of this dimension can prevent cli-
ents and clinicians from using the full array of resources
that have been shown to be helpful (Canda & Furman,
1999; Gotterer; Perry, 1998). Information about a person’s
spiritual perspective and religious beliefs offers insight
601
into the ways they see themselves and the world (Thayne).
definitions of spirituality differ and may or may not be
connected to a person’s membership in a formal religious

group (Canda & Furman; Gotterer). Recent writers have
offered ideas about sensitive ways to conduct a spiritual
and religious assessment (Griffith & Griffith, 2003; Par-
gament, 2007). Although spiritual and religious beliefs
can serve as sources of strength, they can also be prob-
lematic for clients.
We have identified seven potential components of a
social work assessment: social justice, ecological, cross-
cultural, systemic, psychodynamic, biological, and spiri-
tual. Now we will present a model that shows how these
areas are woven together into a formulation.
Model for Formulation: Process and Format
Work with clients inevitably begins with an inquiry
guided by the reasons for referral. during the assessment
phase, information is collected and recorded in a number
of domains including environmental factors, relevant sys-
tems (i.e., family, school, work, etc.), cultural background,
and developmental history. The social worker observes
the client’s appearance, affect, behavior, and ways of relat-
ing and telling his or her story. The client’s strengths are
highlighted. Information collected during the assessment
phase that is considered most important to understanding
the client or situation is then briefly summarized in the
formulation.
The formulation, as written or presented, begins by
repeating the client’s identifying demographic informa-
tion and includes relevant identifying information about
the worker. Each of the parties brings aspects of identity
to the interaction that will affect the relationship, the
possibilities for understanding, and the work they do
together. Including information about the worker makes
it possible to note and highlight differences, similarities,
and the interactive possibilities and challenges.

Information collected during the assessment phase that
is considered most important to understanding the client
or situation is then briefly incorporated in a discussion of
the issues from any of the perspectives that pertain: social
justice, ecological, cultural, systemic, psychodynamic,
biological, and spiritual. The co-constructed formulation
continues with a statement of goals and a plan of interven-
tions consistent with these goals. There can be a consid-
eration of aspects of the clinical relationship that might
be helpful or problematic. If research is available to guide
the treatment planning, it is cited in the formulation as
part of the justification of the intervention to be used. The
formulation concludes with a specification of desired out-
comes and a plan for evaluating results. When possible,
goals are stated in measurable terms, but we would not
restrict goals to those that can be quantified.
The scope of the inquiry and the depth of the formula-
tion are dependent on the client’s concerns, the function
of the agency in which the client is seen, and the time
available for the work. Although the worker is guiding the
inquiry, a collaborative approach should be maintained.
There needs to be a balance between the worker’s use of
questions and space for clients to tell their stories in ways
that are natural and holistic. At the end of the process,
the worker and client together make decisions about
priorities. The following example of a client with whom
one of us worked (Poorvu) is provided to demonstrate
the process of assessment and formulation as illustrated
in Figure 1.

Example
Presenting Problem
Angela, a 20-year-old White Irish woman, is referred for
support by her son’s pediatrician, when 10-month-old
Brian is diagnosed with malabsorption and severe chronic
bowel disease and admitted to the hospital. She reports
that Brian has always been difficult to feed despite her
efforts at trying different types of bottles and formulas.
Brian has numerous stools each day, increasing the money
spent on disposable diapers because Angela does not have
time to wash cotton ones. Angela admits that her frustra-
tion often renders her tearful and hopeless about being
an adequate mother for Brian. She states, “I just thought
Brian was small and troublesome. I didn’t think he was
really sick.” The hospitalization has added to her stress,
despair, and difficulty sleeping.
Summary of Biopsychosocial Information
Angela, a single mother, was abandoned by the baby’s
father, her high school boyfriend, after telling him she
was pregnant. She is determined to manage Brian’s care
alone. Angela lives with her son and mother in a rented

I. Identifying demographic information regarding client and
worker: reason for referral, agency context, presenting problem,
and history of the problem.
II. Summary of relevant biopsychosocial information: This
may
include client’s history, environmental situation, cultural
background, class, family, work and other systems, individual
psychological factors including developmental history,
biological
factors, and spirituality.
III. Formulation: Brief conceptualization of the issues from
social
justice, ecological, cultural, systemic, psychodynamic,
biological,
and spiritual perspectives as relevant.
IV. Exploration of literature for evidence-informed
interventions.
V. Goals, interventions to be used, and justification for
these choices.
VI. Advantages and challenges in the clinical relationship.
VII. Plan for evaluation.
Figure 1. Assessment and formulation outline.
602
apartment (a two-bedroom, third-floor walk-up) in a
working-class, tightly knit, mostly Irish neighborhood

in Boston. In addition to her responsibilities as a mother,
Angela is also caring for her mother, who is frail, has
chronic emphysema, and requires oxygen and an array of
other services. This means that Angela cannot stay over-
night with Brian at the hospital. Her father, an alcoholic,
is homeless, unemployed, and in minimal contact with
the family. Angela’s girlfriends help out, but she knows
that her mother really wants only her. Thus, she feels torn
between the needs of her mother and her son.
Angela had heard stories from her immigrant grandpar-
ents about prejudice against the Irish that they encountered
upon arriving in Boston. She expects similar treatment,
saying that Irish Catholics should “stick to their own
kind.” Her mother insists that one doesn’t share one’s busi-
ness outside of the family. Angela has become increasingly
uncomfortable with the growing Hispanic population in
her neighborhood and with the gang of boys who hang out
at the corner convenience store.
Angela is unemployed. She and Brian have the support
of several government assistance programs, including
Temporary Assistance for Needy Families; the Special
Supplemental Nutrition Program for Women, Infants,
and Children; and medicaid. She wonders if her poverty
will prevent Brian from getting the treatment he needs
at the hospital clinic. His condition requires that he be
fed with breast milk that has to be bought at a high cost.
Angela states, “That must be for rich people; how will I
ever afford it?”
Angela has many close relationships with women friends
and a positive relationship with her mother. demonstrat-
ing her capacity for insight, Angela says that her early
negative experiences with her father made her untrusting
of men in general. She fears that dr. Smith might judge

her for being a “welfare mom” and refuse to be Brian’s
pediatrician.
Angela has never seen a social worker and states, “Strong
people shouldn’t need help.” Angela wonders how it will be
to talk to a non-Catholic social worker. Comforted by her
worker’s being the same age as her mother, Angela decides
to give the relationship a try. The clinician is aware of her
maternal and protective feelings toward Angela, as she
remembers what it was like to be a new mother.
Formulation
This 20-year-old new mother and her family contend daily
with the effects of poverty, poor health, and inequities in the
health care system. Her social worker, a 50-year-old married
Jewish mother of three adult children, lives in comfortable
circumstances and takes for granted access to good health
care. It is important that the worker be mindful of these dif-
ferences in circumstances.
Angela lives fearfully, concerned about the shifting demo-
graphics of her neighborhood and the increase in gun vio-
lence and gang-related crime. She has been raised with core
beliefs about sticking to one’s own kind, and she expects to
be misunderstood by others. She has few models of women
empowered to make beneficial changes, since she has been
surrounded by women who share her circumstances and
sense of a lack of power. She is easily intimidated by hospital
staff and fears criticism from the doctor. Angela appears to
have a secure relationship with her mother. But she is stressed
by being in charge of a multigenerational family with seri-
ous needs, at an age when she might benefit from nurturing.
While she is able to advocate well for herself, and to negotiate
difficult welfare systems, the frustrations at times overwhelm
her and exhaust her problem-solving ability. Her identity as

an Irish American appears to be a source of pride. Likewise,
her strong religious beliefs and rituals sustain her.
Angela seems to be having difficulty taking in the serious-
ness of her child’s illness. She continues to think that he is just
a fussy, colicky baby.
Relevant Writing and Research
The literature concerning social work practice with families
of pediatric patients, which is anecdotal and not research
based, supports the importance of developing an empathic
relationship and validating the parents’ identity as parents
and the decisions they have made. The ongoing assessment
needs to consider the problems that existed before the child’s
illness (dungan, Jaquay, Reznik, & Sands, 1995).
Goals and Interventions
Assist Angela in managing the stress of Brian’s hospi-1.
talization. It is important that the social worker and
staff understand the stress Angela experiences in being
the sole caregiver for her mother and her son. The pos-
sibility of providing parking and food service vouchers
and of arranging for a visiting nurse for her mother will
be explored. offering these services, as needed, will be
helpful in building a relationship with Angela and in
enabling her to recognize that her needs are important
to the staff.
Assist Angela in developing a new view of her son and 2.
his future, as well as her own future. The use of support
and clarification will enable the social worker to pro-
vide a relationship within which Angela can grieve the
loss of the child she expected and develop a bond with
Brian, as he is. Angela has suggested that she has con-
flicted feelings about men, having been abandoned by
her father and her boyfriend. If she is willing, it could be
helpful to explore her feelings about men and how she

imagines it will be to raise a male child in a changing
neighborhood that doesn’t feel safe. The social worker
will explore the ways in which having this baby derailed
other plans she might have had for herself and evaluate
how she is adjusting to the loss of that anticipated life.
603
Support Angela’s strengths. The social worker will 3.
encourage Angela’s current level of functioning by
having her continue to make arrangements for the
concrete services needed upon discharge, including
contacting the Worcester Breast milk Bank. The social
worker will encourage ongoing use of her church and
friends for support.
Referral to a support group for mothers of children 4.
with gastrointestinal disorders. Participation in such a
group might support Angela in her ongoing struggles
with Brian’s care. It could also help her develop an
awareness of social injustices and inequities in the
health care system and help her advocate for better
health care for herself and others like her.
Continue to investigate research specific to helping 5.
parents of children with gastrointestinal disorders. A
search of the Social Work Abstracts database using the
keywords “Pediatric G.I. disorders” uncovered the fol-
lowing citation: Hathaway, P. (1989). Failure to thrive:
knowledge for social workers. Health Social Work,
14(2). Since such disorders might initially present as
failure to thrive, a keyword search using this term elic-
its 37 more articles.

Treatment Relationship
mindful of her maternal feelings toward Angela, the
worker will be careful to empower her by not taking over.
It will also be important to be curious about Angela’s
experience of growing up Irish and to encourage her to
express concerns about religious and ethnic differences
between herself and the social worker. Showing empathy
for the strain of being torn between her mother’s needs
and those of her son will help Angela to feel trusting and
safe; this will enable the sharing of strong feelings.
Plan for Evaluation
Signs of success will include the following:
decreased anxiety and sadness could be measured by 1.
depression scales at the beginning, middle, and end of
the treatment.
Increased comfort on the unit and trust in the staff 2.
would be measured by self-reports and observations of
multiple staff members.
Increased comfort in managing Brian’s care would be 3.
measured according to a decrease in anxious phone
calls and increased instances of advocating for Brian’s
care and making follow-up calls and arrangements.
Increased confidence in her own judgment and efforts 4.
would be evidenced by decreased requests for support
from the worker and increased reports of her success-
ful management of situations.
Conclusion
Every clinical situation is unique and leads to the collec-
tion of information and development of a formulation
specific to the particular circumstances of that situation.
At the same time, the values and interests of the social

work profession require a broad approach to assessment
and formulation that integrates social justice, ecological,
systemic, biological, cultural, spiritual, and psychological
perspectives. At this time in the history of social work,
there are pressures to reduce, simplify, and reconfigure
the assessment and formulation process in ways that will
redefine practice. We advocate a model for assessment
and formulation that is broadly conceived. It contains
components historically important in social work; our
model reconfigures them in the light of contemporary
theories and approaches. With a comprehensive model
for assessment and formulation, we can sustain the rich-
ness of multiple orientations and understandings that best
inform our work.
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Article
Examining the effectiveness of the
Cultural Formulation Interview with
young children: A clinical illustration
Martin J. La Roche1 and Jill Betz Bloom2
Abstract
After years of extensive research, the Cultural Formulation
Interview (CFI) was released in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-
5). Similar to its predecessor, the Outline of the Cultural
Formulation (OCF), the CFI aims to refine the psychiatric
assessment process by systematically examining cultural
factors.
However, in contrast to the OCF which employs open-ended
questions, the CFI uses a semi-structured interview format.
Unfortunately, children and adolescents have only been
included in a handful of OCF and CFI studies, which raises
questions
about their applicability with youth, particularly young children
(11 years or younger). In this article, we start examining the

usefulness of the CFI with young children and propose
recommendations to enhance its benefits by suggesting the
devel-
opment of a supplementary module specifically designed for
young children. These ideas are illustrated with the assessment
of a 6-year-old boy of Somali descent.
Keywords
assessment, children, cultural diversity, Cultural Formulation
Interview, refugees, Somali
The Cultural Formulation Interview (CFI) was first
introduced in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5;
American Psychiatric Association (APA), 2013). The
CFI is a more standardized version of the Outline of
the Cultural Formulation (OCF), which was first
described in the DSM-IV (APA, 1994). The CFI oper-
ationalizes many of the OCF’s questions into a semi-
structured interview composed of 16 questions with
explicit instructions to assess an individual’s experience
and social context. While the OCF was relegated to the
ninth appendix of the DSM-IV (APA, 1994), the CFI is
described in the more prominent section III of the DSM-
5 (APA, 2013), which seems to reflect its increased cred-
ibility (La Roche, Fuentes, & Hinton, 2015).
The CFI was designed to identify cultural and con-
textual factors relevant to the diagnosis and treatment
of different problems; it aims to more accurately under-
stand patients’ symptoms and world views by examin-
ing them in relationship to their cultural context. The

underlying assumption of the CFI is that culture shapes
a patient’s perspective and approach to clinical care,
influencing when, where, how and to whom patients
narrate their experiences of illness and distress
(Kirmayer, 2006). In addition, the authors of the CFI
(Lewis-Fernández, Aggarwal, Hinton, Hinton, &
Kirmayer, 2016) underscore culture’s fluidity and con-
ceptualize it as an open dynamic system that undergoes
continuous change over time. Furthermore, the CFI
authors explain that most individuals and groups are
exposed to multiple cultures and socioeconomic con-
texts (Lewis-Fernández et al., 2016).
In contrast to the DSM-5’s prevalent biomedical
view of disorders as constellation of symptoms that
are accurately examined independently of their cultural
context, in the CFI mental health disorders are concep-
tualized as embedded in cultural contexts (La Roche
et al., 2015; Regier, Narrow, Kuhl, & Kupfer, 2011).
The CFI explores symptoms as locally shaped by dif-
ferent cultural contexts.
Transcultural Psychiatry
2020, Vol. 57(4) 515–524
! The Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1363461518780605
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1Boston Children’s Hospital and Harvard Medical School
2William James College
Corresponding author:
Martin J. La Roche, Boston Children’s Hospital/Harvard
Medical School,
75 Bickford St, Jamaica Plain, MA 02130, USA.
Email: [email protected]
https://uk.sagepub.com/en-gb/journals-permissions
https://doi.org/10.1177/1363461518780605
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18780605&domain=pdf&date_stamp=2018-06-29
Directly assessing patients’ cultural characteristics
and contextualizing their symptoms allows clinicians
to design psychotherapeutic treatments based on these
characteristics rather than cultural stereotypes (Lewis-
Fernández et al., 2016). Furthermore, directly assessing
patients’ cultural beliefs, idioms of distress or meanings
helps practitioners avoid misdiagnosis, obtain clinically
useful information, improve clinical rapport and thera-
peutic efficacy, guide research and training, and clarify
cultural epidemiology (Lewis-Fernández et al., 2016).
In fact, there is a growing literature that demonstrates
that complementing psychiatric assessments with the
OCF or CFI significantly increases the accuracy and
cultural validity of DSM’s diagnoses (Bäärnhielm, S.,
Åberg Wistedt, & Scarpinati Rosso, 2015; Kirmayer,
Thomb, Jurcik, Jarvis, & Guzder, 2008; Lewis-

Fernández et al., 2016). Nevertheless, employing the
CFI by itself does not result in a diagnosis. The infor-
mation obtained by the CFI must be integrated with
other clinical material to produce a comprehensive clin-
ical and contextual evaluation. In addition, it is import-
ant to clarify that the CFI guidelines do not require
clinicians to have a thorough knowledge of their
patients’ cultural background. However, an enhanced
knowledge of patients’ cultural background often
increases CFI’s diagnostic accuracy (Lewis-Fernández
et al., 2016).
The CFI is described as ‘‘a work in progress’’ or a
‘‘living document that will be modified with new know-
ledge’’ (Kirmayer, 2016, p. 268). The CFI (see
Appendix 1 in the Supplemental Online Material)
explores the following four areas: 1) Cultural definition
of the problem; 2) Cultural perceptions or understand-
ing of the cause(s) of the problem, which includes two
subareas, stressors/supports and role of cultural iden-
tity; 3) Cultural factors affecting self-coping and past
help-seeking; and 4) Cultural factors affecting current
help seeking. Two versions of the CFI are available,
one for patients (which will simply be referred to as
CFI) and a CFI-Informant Version. The CFI is directly
administered to patients and gleans information from
their own world view, while the CFI-Informant Version
is completed by significant other(s) of patients or
people who can provide relevant information about
them or their context. The CFI-Informant Version
aims to assist clinicians in conducting a cultural assess-
ment of the presenting clinical problem from the per-
spective of key informant(s) such as spouse, other
family member(s), teacher(s) or other significant per-
son(s) in their life who can offer clinically relevant
information. When collateral information is possible,

the CFI-Informant Version supplements what patients
report or it may become the primary source of infor-
mation when patients are unable to participate actively
in their assessment, such as in the case of young
children, individuals with cognitive impairment or
florid psychosis (Lewis-Fernández et al., 2016). Often,
only the CFI-Informant Version is used with the par-
ents and/or teachers of a child, while neither CFI ver-
sion is directly used with children, particularly young
children (Rousseau & Guzder, 2016). Both CFI ver-
sions measure the same four areas but the CFI-
Informant Version does so from the perspective of per-
son(s) close to the patient and it includes the following
question: ‘‘How would you describe your relationship
to the patient?’’
Both CFI versions can be complemented by one or
several of the 12 Supplementary Modules (e.g., cultural
identity). Each of these 12 modules provides additional
and more detailed questions to assess specific domains
briefly explored in the CFI as well as questions that can
be used during the cultural assessment of particular
groups, such as children and adolescents, older adults,
and caregivers. Evaluators can decide to use several or
none of these 12 supplementary modules.
Over 150 published studies have employed the OCF.
Given the CFI’s semi-structured format, it is likely that
a greater number of research studies will soon start
benefiting from its easier use (Lewis-Fernández et al.,
2016). However, the vast majority of OCF studies have
used adult samples. Only a handful of publications
were identified that have used the OCF with children,
particularly young children. In this paper, the term
‘‘young children’’ refers to youth who are 11 years of

age or less, or youth who have not reached the formal
operations stage. According to Piaget (1972) the formal
operations stage is the last cognitive stage in an indi-
vidual’s development and it entails an ability to think in
abstract terms and think critically and comparatively
about situations. The age at which the formal operation
stage emerges varies from culture to culture but in
industrialized and highly-educated countries it often
starts developing around the time the child is 11 years
of age (Cole, 1998).
The handful of researchers (i.e., Novins et al., 1997;
Mian, Al-Mateen, & Cerda, 2010) who have employed
the OCF with children have consistently noted its
potential to assess cultural issues and suggested that
the paucity of OCF research is explained by the fact
that it was designed for adults. As a means to address
OCF’s significant limitations in assessing children, the
CFI incorporated two main additions (Rousseau &
Guzder, 2016). First, it included the CFI-Informant
Version that is administered to people who are signifi-
cant in a child’s life, such as parent/guardian(s) and
teachers, and second, it crafted a supplementary
module 9 entitled ‘‘School-Age Children and
Adolescents’’ (SACA) to be directly administered to
the child (see Appendix 2 in the Supplemental Online
Material).
516 Transcultural Psychiatry 57(4)
The first improvement underscores the importance
of using the CFI-Informant Version with children’s
parent(s) or guardian(s), which acknowledges that
they are key to their children’s clinical presentation.

In addition, the possibility of having several people
complete supplemental forms reflects the complexity
of cultural views and contexts. The child is exposed to
multiple cultural influences at home, school, and in
their communities. Even within the same family each
parent or sibling may have distinct cultural views (e.g.,
different acculturation levels) that can be assessed
through different informant versions.
The development of a supplementary module for
SACA is a second significant improvement included
in the CFI to assess children. The SACA module is
designed to help clinicians explore age-related cultural
dimensions. The questions are purposefully indirect to
allow children or adolescents to express their feelings of
being special or different or from a specific culture. The
questions are written to yield the child’s representations
of normality at home or challenges growing up at
school, with friends or their community, which
acknowledges that a child’s normal development is
defined in cultural terms. The module includes 20 ques-
tions in four main areas.
However, even this module specifically designed for
children and adolescents contains the following caveats,
‘‘this supplement is directed to adolescents and mature
school-age children. . . Some children may not be able
to answer all questions; clinicians should select and
adapt questions to ensure they are developmentally
appropriate for the individual’’ (Lewis-Fernández
et al., 2016, p. 309), which raises questions about its
utility with young children. It is likely that the devel-
opers of this module were concerned that its questions
required formal operations thinking and that it relied
too heavily on language. For example, question 14 (i.e.,
What do other children/youth your age expect from

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