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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

journals.sagepub.com/home/tps

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]

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
child/youth your age?) may not glean very different
information from question 13 (e.g., What do your par-
ents or grandparents expect from you?). The difference
between questions entails contrasting contexts, which is
a formal operation skill.

Kirmayer (2016) explains that the CFI has much
potential as an assessment tool, yet it is still unclear
how it is used in the clinical process. This is particularly
important as assessment and treatment processes are
not independent from each other. Furthermore,
Kirmayer (2016) argues that the CFI stopped short of
creating a more structured template that could link and
organize the assessment data to clinical issues. In the
assessment of young children, we outline several ideas
to connect the information yielded by the CFI to the
psychiatric assessment, which could be very useful for
mental health providers working with young children

who need to glean and organize information from mul-
tiple sources (e.g., school, family). Having an outline to
organize this information may not only clarify the
information but also save time. Not considering cul-
tural information can lead to significant assessment
and clinical errors (Kirmayer, 2016). As a result, clin-
icians and researchers may start viewing the CFI as an
invaluable tool to organize information in a more cul-
turally valid manner instead of viewing it as another
cumbersome scale to administer. However, to outline
this process we need to start by briefly describing the
psychiatric assessment and its main components.

The psychiatric assessment is the process of gather-
ing information by a mental health provider (e.g.,
psychiatrist, social worker) about a patient within a
psychiatric or mental health service with the purpose
of making an accurate diagnosis (Angold et al., 1995;
Maxmen & Ward, 1994). The psychiatric assessment is
the first stage of any mental health treatment. Many
outlines to conduct psychiatric assessments have been
developed. Nevertheless, most include the following six
components (Maxmen & Ward, 1994): 1) ‘‘Chief
Complaint(s)’’ in which the main reason(s) patients
are seeking mental health services are described; 2)
‘‘History of Problems’’ or how patients’ problems
have evolved through time; 3) ‘‘Mental Status’’ or the
symptoms patients are presenting; 4) ‘‘Diagnosis’’
which is a category(s) that reflects the constellation of
symptoms patients are presenting; 5) ‘‘Biopsychosocial
Formulation’’ or an explanation of why patients are
experiencing certain symptoms and; 6) ‘‘Treatment
Plan’’ or a systematic set of strategies designed to
ameliorate patients’ symptoms. Additional components
have also been used in the psychiatric assessment
(Maxmen & Ward, 1994) (e.g., prognosis, physical
examination), which are not herein included because
they are not significantly influenced by the information
yielded through the CFI. The way in which each of
these six psychiatric assessment components is
informed by the four areas of the CFI are outlined
and illustrated through a psychiatric assessment of a
6-year-old boy of Somali descent conducted by the
first author of this article, who is a Latino, male psych-
ologist in his mid-50s. The goal of this paper is to start
examining the utility of the CFI with young children
and to suggest strategies to refine its use with young
children. To ensure confidentiality identifiable data
has been disguised or modified.

Case example

Jamaal came to the clinic located in their neighbour-
hood with his mother and interpreter. The clinic is the
oldest standing community health center in the United
States and has a long tradition of serving and

La Roche and Bloom 517

welcoming diverse communities. The same interpreter
was present for both assessment sessions. Before the
session, all releases, consents, and confidentiality agree-
ments were explained and signed. Jamaal was a well-
groomed boy, with a shy smile and bright eyes, and
appropriately dressed for the fall weather. He was
born in Boston six years ago to Somalian parents.
Jamaal speaks English fluently but his parents have a
very limited understanding of English and are unable to
express themselves in English. His parents recently
separated for unspecified reasons. Although his father
now lives in a different town he still visits Jamaal and
his four siblings every day. Jamaal is the youngest; his
two brothers are 22 and 17 years of age and his sisters
are 15 and 8. Jamaal reported having a good relation-
ship with his parents and each of his siblings.

His parents arrived in Boston 25 years ago fleeing
escalating violence in Somalia. Civil war broke out in
Somalia in 1988 leading to a massive population dis-
placement that continues to this date. Currently, the
Somali and Somali Bantu populations are the largest
African groups living in the United States (Johnson,
Ali, & Shipp, 2009) and constitute 45% of the
African refugee population (Carroll et al., 2007). As a
result of the civil war and the immigration journey to
the US, many families have experienced severe violence.
These traumatic experiences are often compounded in
the US by resettlement stressors, acculturative stres-
sors, poverty, and discrimination (Betancourt, Abdi,
Ito, Lilienthal, & Agalab, 2015). Research indicates
that among relocated Somalis, mental health diagnoses
such as depression, post-traumatic stress disorder
(PTSD), and anxiety range from 14% to 31.5% of the
population (Boynton, Bentley, Jackson, & Gibbs, 2010)
with 50% prevalence rate in some studies (Guerin,
Guerin, Diiriye, & Yates, 2004).

Despite Somalis’ extensive need for mental health ser-
vices, they rarely seek help. Furthermore, children utilize
services even less often than adults (Ellis et al., 2010).
Multiple barriers (e.g., language differences, difficulty
accessing health services) often deter Somalis from seek-
ing mental health services. However, researchers (e.g.,
Bettmann, Penney, Clarkson-Freeman, & Lecy, 2015;
Ellis et al., 2010) explain that underutilization is also a
result of Somalian cultural beliefs that often clash with
Western mental health assumptions. For example, many
Somalis believe that having PTSD or depression is a sign
of weakness that is best dealt with by staying at home.
Rather than seeking outside services families encourage
their ill family members to stay home as a means to
protect them from being publicly humiliated or insulted
(Bettmann et al., 2015).

I first met with Jamaal’s mother, Mrs. S. while
Jamaal played quietly in the waiting area. Mrs. S was
a tall, slim woman in her late-30 s wearing a colorful

and highly ornamented hijab or veil. In an effort to
establish rapport with her I inquired about transporta-
tion issues. Once I felt that rapport had been estab-
lished I asked ‘‘what brings you here?’’ which is the
first question of the CFI informant version. This is
also the first question of many psychiatric assessments
and addresses patients’ chief complaint. She said ‘‘my
son’s pediatrician Dr. O. recommended that Jamaal
receive counseling.’’ Following CFI’s outline, I added.
‘‘People sometimes understand their problems in their
own way, which may be different from the way in which
doctors describe the problem.’’ Jamaal’s mother pro-
ceeded to explain that her eldest son Mohamad, 22
years of age, was shot in front of their home and that
he is still recovering from numerous gun wounds. The
‘‘criminal was never caught by the police.’’ According
to traditional Somali culture, an assault to a family
member is an affront to the entire family, which reflects
the close-knit kinship relationships emphasized in
Somalia (Wolf et al., 2014). Frequently after an assault
mental health assistance is not sought; instead the
assailant is required to pay damages to the family
(Scuglik, Alarcón, Lapeyre, Williams, & Logan,
2007). Overall, this information about Somalian culture
was used as hypotheses that could clarify Jamaal and
his family’s experience. Nevertheless, these hypotheses
had to be confirmed by their narratives (Kleinman,
1988; La Roche, 2013), which seemed to be the case
as Jamaal’s mother said, ‘‘I don’t think the police
care about Africans because they never caught the
criminal.’’ The mother’s focus was on capturing the
shooter so that he would have to compensate the
family for the assault. She added that ‘‘they [police]
don’t care about us or they would have caught the
criminal. . . shootings are very frequent where we live.
Our next-door neighbor was also shot a few months
ago. We live in a very dangerous neighborhood. . .’’

Mrs. S. explained that the frequent neighborhood
shootings were making Jamaal very nervous; he was
having nightmares and he was not eating at school.
Even his pediatrician was worried because he had lost
weight. Mrs. S. continued, ‘‘after Mohamad [eldest son]
was shot, Jamaal has not been the same. Before the
shooting Jamaal was a happy child but now, he
doesn’t go outside by himself. He doesn’t eat breakfast
at school and he doesn’t play with his friends.’’ I asked
how he played with his friends before and after the
shooting. His mother responded, ‘‘before he never
seemed afraid of going out but now he seems afraid of
walking alone on the street.’’ She identified his night-
mares, poor appetite and fear of walking alone as the
most troubling aspects of his behavior, which were a
response to question 3 of the CFI, which is also a good
question to start exploring patients’ mental status. I
asked many additional questions examining his mental

518 Transcultural Psychiatry 57(4)

status. As his symptoms were identified a history of
problems was also completed. It was found that before
his brother was shot he did not present anymajor mental
health symptoms (e.g., nightmares, lack of appetite).

In exploring the cultural perceptions (CFI’s questions
4–7) of the causes of Jamaal’s problems his mother
explained that the shootings were the main reason for
his problems. She indicated that Jamaal’s father and
extended family also believed this was the case. One of
the advantages of the information gleaned through the
CFI questions is that it can add cultural specificity, not
typically obtained, using standard psychiatric assess-
ments. For example, as I continued to explore what vio-
lence and Jamaal’s symptoms meant for them, Mrs. S.
angrily said,

Americans do not care about Africans or Muslims.

Whites have dumped us in a bloody neighborhood so

that we kill each other. This is what Donald Trump

wants, isn’t he saying that he wants to get rid of all

Muslims?

Having experienced much discrimination from white
people, Jamaal’s family found it difficult to trust
them. I understood this could become a significant
treatment barrier and that it should be addressed as
soon as possible. Nevertheless, she quickly moved on
to talk about housing issues.

Mrs. S. then described her repeated efforts to move
out of the neighborhood and her frustration in com-
pleting subsidized housing applications. Her English
was not good enough to complete these forms, which
would allowed me to further explore her self-coping
and past help-seeking behavior when facing significant
challenges (CFI question 11–13). Jamaal’s mother iden-
tified that two crucial barriers for the well-being of her
family were poverty and living in a violent neighbor-
hood. She said that ‘‘it is very frustrating to seek help.
When I phone people, they hang up on me. They do not
understand my English but I keep trying for my
family.’’ I offered to refer her to a case manager, to
which she responded that in the past case managers
had been useless. She explained that her previous case
manager was ‘‘a very busy woman who did not seem to
have time for my family. She did not answer my ques-
tions just like most Whites don’t. Whites don’t care for
Muslims. . .’’

In inquiring about her preferred types of help (CFI
questions 13–15) I asked her what I should do to ensure
that I did not make the same mistakes since I am not
Muslim nor African. She answered that, ‘‘I should
really try to care.’’ I asked her to explain what she
meant by caring as it means different things for differ-
ent people. Smiling, she said that we would have to
work together to find that out. I asked further what a

good relationship would look like and she said that she
would surely tell me if I was not caring enough.

Some of the CFI identity questions (questions 8–10)
were not addressed in order or even during the same
assessment session but much information was provided
about their identity from the onset and throughout the
assessment. For example, I realized that Mrs. S. used
the plural form of words frequently, using the word
‘‘we’’ to refer to herself, Jamaal, or the family.
Although, most people would agree that it is impossible
to work with a child without the family, I soon realized
that her identity and family were intricately interwoven.
Her identity was more a reflection of family relation-
ships than an individualistic, isolated construal of the
self. Reflecting this view, in the treatment plan I under-
scored the importance of including the family in the
psychotherapeutic process. Moreover, her identity as
a Muslim and African was central and often construed
in opposition to American traditions and assumptions.
She believed that because of her family’s religion, skin
color, and place of birth they were discriminated
against and marginalized in Boston.

Consistent with CFI guidelines (question 16) I fur-
ther explored the meaning of cultural differences. I
encouraged her to discuss any concerns that she
might have had because I am Latino and not Muslim.
Nevertheless, it is important to note that many add-
itional cultural differences are also present, such as
gender and educational level, that needed to be dis-
cussed (La Roche, 2013). However, many patients
choose not to address cultural differences during the
first few sessions. Most patients have many and more
pressing issues to discuss. Nevertheless, by asking the
CFI questions the message was conveyed that it was
appropriate to discuss cultural differences within the
psychotherapeutic session. Some patients choose to
take advantage of this possibility in later sessions (La
Roche, 2013).

After Jamaal came to the office I asked a few rap-
port-building questions before I asked the first question
of the CFI to which he did not seem to know how to
respond. Even after I clarified the question he just
looked to the floor. I then proceeded to administer
the SACA supplementary module (see Appendix 2 in
the Supplemental Online Material) and I asked, ‘‘I
would now like to know more about your feelings
about being 6 years of age?’’ He limited himself to
say, ‘‘it’s ok.’’ I then asked ‘‘do you feel like other chil-
dren/youth your age?’’ to which he did not seem to
know how to respond. The interviewer has repeatedly
experienced the same situation where young children of
different ethnic backgrounds do not know how to
respond to any of the CFI’s questions including the
SACA module. More often than not the answer is ‘‘I
don’t know’’ or ‘‘my mother brought me here.’’

La Roche and Bloom 519

I asked Jamaal if he would like to draw or build
something and he took some paper and crayons and
started drawing four thick walls that looked like a
‘‘fort’’ and he drew himself inside. He stated that ‘‘he
was in his home playing ball.’’ I asked how it is to be
home and he responded, ‘‘it’s good inside the house,
but outside it’s bad.’’ He did not respond when I
asked him to draw the outside. I then asked him what
is good about being inside and bad outside and he said,

Inside I have my family and we are happy together, but

outside there are many shootings. . . One time my

brother was shot. Many policemen and ambulances

came. There were lots of people. . . Another time I

was looking outside the window and there was another

shooting. I am very scared. I am scared that I will get

shot. I am scared that my mom will get shot. . . I am

scared of going outside so I stay inside. I play with my

tablet, watch TV and play with my sisters.

Following the SACA module questions I inquired
about stressors and supports. His family was identified
as a source of support while his neighborhood was
viewed as a dangerous and stressful place.

In addition, he reported having frequent nightmares
in which he was shot by streets thugs or kidnapped,
‘‘they are very scary’’ he explained. Furthermore,
Jamaal reported often feeling dizzy and that his heart
beat very quickly. Jamaal also had difficulty breathing
and even feeling some ‘‘belly ache.’’ This was particu-
larly true if he heard a loud or unexpected noise.
Jamaal added, ‘‘my eyes get fuzzy and my head
hurts. . . every time I am dizzy something bad happens.’’

As I continued to explore stressors and supports I
learned that Jamaal and his family were very supportive
with each other and their Somalian next-door neigh-
bors. When I asked Jamaal what made him feel
happy he did not say anything but immediately started
drawing his family. He drew 12 family members all very
close to each other and he indicated that they were
smiling because they were ‘‘happy together.’’ Five of
these 12 were his neighbors. In addition, Jamaal drew
himself very close to his mother and spontaneously
reported loving his mother and in turn, his mother
smiled at him and said, ‘‘I love you, too.’’

In many groups such as in the Somali culture,
‘‘family’’ is defined differently than in the typical
Western nuclear family; it may not only include blood
relatives but also close friends (Wolf et al., 2014). This
understanding may have implications when utilizing
different play therapy tools such as doll houses that
encourage children to reflect family dynamics in their
own language. Instead of using one doll house as sug-
gested by most play therapy texts I have used several
doll houses to more thoroughly capture their

experiences. This approach was particularly useful
with Jamaal because when I asked him about his
family he immediately started playing with my doll-
houses. Suddenly, Jamaal loudly said ‘‘bang’’ and all
the human figures ran from the first dollhouse to the
second. He again yelled ‘‘bang’’ and now all the figures
ran from the second house to the first. His mother
explained that her family would often run to their
neighbor’s home if they heard a shooting closer to
their home than that of their friends. Similarly, their
neighbors would hide in Jamaal’s home if the shooting
seemed closer to the neighbors’ home. Jamaal added
that he felt safer and stronger together. Mrs. S. con-
cluded that ‘‘family is good.’’

Jamaal also reported feeling safe as he heard the
words of the Qur’an and he reported enjoying asking
questions about it. Many of his siblings would also join
in during these readings that seemed soothing not only
for Jamaal but for the entire family. In much of the
Somalian mental health literature (Bettmann et al.,
2015; Tiilikainen & Koehn, 2011) religious beliefs and
practices are underscored as a source of support.
Consistent with his self-report and Somalian mental
health literature I encouraged Jamaal to recite prayers
whenever he felt that his heart was pounding quickly or
that he could not breathe. He realized that as he heard
the words of the Qur’an he felt more relaxed. He and
his mother explained, ‘‘Allah is great and He is giving
us strength.’’ This belief could have motivated him to
pray which in turn may have heightened his sense of
mastery over his anxiety symptoms. It was clearly noted
in the treatment plan that Jamaal would benefit from
relaxation strategies that incorporated prayers rather
than more traditional guided imagery. If the CFI had
not been used, standard relaxation strategies that are
not consistent with Jamaal’s cultural frame may have
been used, which could have reduced treatment adher-
ence and outcome (La Roche, 2013). Similarly, empha-
sizing treatment with Jamaal’s family (e.g., praying
together) rather than working with him alone was a
result of Jamaal’s relational/family world view.

When I asked Jamaal to draw himself at school he
did so alone in a class and did not say much more. Mrs.
S. indicated not knowing how he was doing at school.
She explained that Jamaal’s previous teacher had been
in frequent contact with her. However, his current tea-
cher was not as good and added ‘‘I have not talked with
her.’’ She explained that parents are not supposed to
bother teachers with questions, which is why she had
not reached out to her. Nevertheless, she said that it is
okay for me to call his teacher. Per her request, I
phoned the teacher. I was hoping to administer the
CFI-Informant Version but the teacher’s fast and
abrupt response style only permitted me to ask a hand-
ful of questions. The teacher started by saying ‘‘I have

520 Transcultural Psychiatry 57(4)

only known him for the month of September so I don’t
know him well, but he seems like a shy and easy-going
boy that talks okay with his peers.’’ She quickly added
‘‘I have no worries about him, he is a charming and
sweet child.’’ After a few more comments she reported
having to go back to class.

In an effort to outline treatment goals I said, ‘‘it
seems that much of our work will be in finding ways
for Jamaal to start eating, feel less nervous, have fewer
nightmares and start having friends.’’ Immediately,
Jamaal and his mother nodded. One of the first findings
within the cultural psychotherapeutic literature is that
having agreed upon psychotherapeutic goals increases
the likelihood that patients remain in treatment (Sue,
1977). Numerous authors underscore the need to clarify
treatment goals in a culturally sensitive manner, which
means in terms that are clearly understood by patients
and clinicians. To accomplish this goal, it is often bene-
ficial to clarify and use patients’ terminology (e.g., diz-
ziness, headaches). Understanding and using patients’
language has repeatedly been found to promote empa-
thy and improve the psychotherapeutic relationship.
Furthermore, their concerns led us to formulate two
additional sets of treatment goals. First, to assist the
family to move out of their neighborhood for which I
wrote a letter of support. Second, to help them receive
food stamps for which I assisted them in their welfare
application. However, I also clarified expectations. I
validated their concerns that I may not be able to
help them move out of their neighborhood as quickly
as they wished. Nevertheless, I also assured them that I
would do everything in my power to help them. In add-
ition, I made it clear that in the meantime we would
focus on helping Jamaal. I asked them if this is what
they needed from me and they agreed. I also reminded
them that we could add and revise these treatment goals
at any time.

Psychiatric assessments require a DSM-5 diagnosis
which is clarified with information from the CFI.
Jamaal met all eight PTSD criteria as described on
the DSM-5 (APA, 2013). Consistent with PTSD’s cri-
terion A, Jamaal was directly exposed to significant life
threating events (e.g., his brother was shot and he had
witnessed frequent shootings). Criterion B is that he
presents with recurring involuntary memories asso-
ciated with trauma (e.g., nightmares). Jamaal is also
meeting criterion C as he is also persistently avoiding
stimuli associated with the traumatic event (e.g., not
going outside). Criterion D is experiencing negative
alterations of mood or cognitions related with trau-
matic event(s), which Jamaal also meets. For example,
he is frequently very anxious and fearful that criminals
will attack his home. Similarly, criterion E is met, which
is experiencing significant alterations in arousal and
hyperactivity (e.g., tachycardia, breathing problems).

Symptoms have lasted for over one month meeting cri-
terion F. Similarly, criterion G is also met as he has
started to present significant social impairments at
school. Finally, criterion H is also met as the disturb-
ance is not attributable to physiological effects of a
substance or a medical condition.

Jamaal may have met criteria for PTSD according to
the DSM-5 (APA, 2013); nevertheless, he and his
family have understood his issues very differently. In
contrast to the DSM-5 that underscores symptoms
residing within patients, they viewed Jamaal’s issues
as inseparable from the social context. Jamaal’s prob-
lems were a result of countless and ongoing unjust
socioeconomic and political conditions that have
harmed them even before his birth. These injustices
range from distant events such as the outbreak of the
civil war in Somalia to the everyday violence experi-
enced in their neighborhood in the US, to more current
events such as President Trump’s anti-Muslim rhetoric
during the 2016 presidential race. Furthermore, these
issues do not only reside within Jamaal but within the
family and social context. Therefore, treatment should
focus on helping his family and not only on ameliorat-
ing Jamaal’s symptoms but also on improving or
‘‘treating’’ the social context (e.g., helping them
move). Finally, Jamaal’s family viewed his problems
not as symptoms; rather as reactions to abnormal and
unjust situations. (Bloom, 2016). Jamaal’s clinician will
benefit if he uses a vocabulary that is consistent with the
family’s cultural understanding as a means to avoid
pathologizing and stigmatizing them (Kleinman, 1988;
Lewis-Fernández et al., 2016). If this language is not
used it is likely that the family will drop out of treat-
ment (La Roche, 2013). One of the main advantages of
the CFI is that it encourages patients’ narratives to be
viewed from their own perspective. Furthermore, the
information yielded by the CFI is not final but an
ongoing approximation to their current point of view,
which underscores the need to continuously assess
patients’ cultural views (Lewis-Fernández et al., 2016).

Conclusion

As illustrated in Jamaal’s case the CFI is a powerful
tool to accurately assess in a culturally sensitive manner
young children’s symptoms. The questions of the CFI
can address issues that may have been omitted or not
explored sufficiently by standard psychiatric assess-
ments. For example, issues of mistrust towards white
people are rarely examined in psychiatric assessments,
but thanks to the CFI these were directly assessed in
Jamaal’s assessment. If these cultural differences had
not been discussed, it is likely that past therapeutic rup-
tures (e.g., not caring enough) would have been repli-
cated during the assessment process. Similarly, the CFI

La Roche and Bloom 521

questions allowed the design of a more thorough treat-
ment plan that included prayers and family supports.
The inclusion of cultural characteristics within the
treatment plan often enhances treatment adherence
and outcome (La Roche, 2013; Lewis-Fernández
et al., 2016).

Even though Jamaal’s views (e.g., through drawing
and play) were a significant contribution in developing
a cultural understanding of his issues, the standard
questions of the CFI were not very helpful in reaching
this understanding. Jamaal did not respond to most of
the traditional questions of the CFI including the
SACA module. Much of the information gleaned
through the standard administration of the CFI was
provided by Jamaal’s mother and his playing and draw-
ing. The CFI relies much on language and more
advanced developmental (e.g., formal operations think-
ing) questions that often do not take sufficient advan-
tage of young children’s views. Children often express
themselves more concretely through drawings or play.
Given these limitations and in agreement with the spirit
of the CFI, which is eloquently described (Kirmayer,
2016) as a living document with much flexibility and
potential for growth, the development of a supplemen-
tary module for young children is herein suggested.

The development of an additional supplementary
module for young children is based on the idea that
formal operations and advanced language skills are
not necessary to tap into children’s’ cultural views.
Concrete questions and play can reveal much of chil-
dren’s cultural perspectives. For example, instead of
relying solely on words, children can be encouraged
to draw, build/sculpt (e.g., cutting cardboard/paper
using or play dough), act (through puppets or role
play dramatizations) or any other means that they
choose to represent their views of themselves and
their significant contexts/worlds, including: 1) home/
family, 2) school 3) their neighborhood, and 4) self.
Children can first be asked to describe each context
(e.g., school, home) independently of others. More
detailed questions can follow up on specific issues of
each category (e.g., what is happening and what will
happen in the street?) as well as the SACA module
questions. Clearly, these are preliminary ideas and
more research is needed to develop a supplementary
module with young children.

Our proposed supplementary module for young chil-
dren would necessarily rely on a play therapy tool box
that includes puppets, dollhouses, play dough, etc.
Nevertheless, a cautionary note when using play ther-
apy tools is that these are often culturally biased (e.g.,
skin color of the puppets or use of only one dollhouse).
It is thus necessary for clinicians and researchers to
examine the cultural applicability of each of these
tools with their patients before they are used.

In addition, some ideas to start linking the CFI with
the psychiatric assessment with young children have
been outlined throughout the clinical illustration. It is
hoped that by linking the four CFI areas to the psychi-
atric assessment clinicians and researchers working
with young children and who often need to obtain add-
itional information from several sources (e.g., school)
in comparison with clinicians working with adults, will
not only be able to more effectively organize their infor-
mation but also obtain more in-depth and useful clin-
ical information. The first two CFI questions about the
cultural definition of the problem, for example, can
be used to understand patients’ chief complaint or the
reasons for which they seek treatment. Question 3 is a
good start to explore patients’ mental status. It is neces-
sary to ask in a culturally sensitive manner additional
questions to obtain a complete mental status. The cul-
tural perceptions of the causes of the problems (ques-
tions 4–10) can inform the development of a shared
understanding of what caused the problems or formu-
lation, after which treatment goals can be defined and
prioritized. Exploring past help-seeking and self-coping
(questions 11–13) as well as the questions of current
help-seeking (questions 14–16) can allow patients and
clinicians to design more culturally competent healing
strategies (e.g., including prayers) and/or refine existing
ones.

One single case illustration is insufficient to offer a
thorough examination of the CFI with young children.
Nevertheless, it is hoped that Jamaal’s case highlights
the need to listen to young children’s voices and cul-
tural interpretations. Unfortunately, their voices have
often been neglected from the cultural literature. This
lack underscores the need to continue researching and
refining the utility of powerful cultural tools such as the
CFI with young children.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this

article.

Funding

The author(s) received no financial support for the research,
authorship, and/or publication of this article.

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Martin J. La Roche, PhD, has been Director of
Training at the Martha Eliot Health Center at Boston
Children’s Hospital, which is the oldest standing com-
munity health center in the country, for the last 22
years. He is an Associate Professor in Psychology at
the Harvard Medical School/Boston Children’s
Hospital and specializes in the development of cultur-
ally competent psychotherapeutic and assessment stra-
tegies. Dr. La Roche has over 100 peer reviewed
publications/presentations on cultural competent treat-
ments with ethnic minorities and has been Principal or
Co-Principal Investigator on many research projects.
Dr. La Roche is also the author of a book entitled
Cultural Psychotherapy: Theory, Methods, and
Practice. In addition, he has received many research/
academic awards such as the Harvard Bridge Award,
The Milton Award, and was Selected Outstanding

La Roche and Bloom 523

Committee Chairperson of the Year by the
Massachusetts Psychological Association.

Jill Betz Bloom, PhD, is an Associate Professor in the
Department of Clinical Psychology at William James
College in Boston, where she is Co-Director of the
Center for Multicultural and Global Mental Health,
and Director of the Global Mental Health Program.

Dr. Bloom’s current work in global mental health
includes co-leading service learning immersion pro-
grams in Haiti and Guyana, with a focus on community
capacity building. Her research and publications focus
on sex trafficking, global gender violence and trans-
national feminism, and a book project on the social
and cultural history of psychiatric diagnosis.

524 Transcultural Psychiatry 57(4)

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

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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,

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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

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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.

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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.

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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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Ruth G. Dean, Phd, LICSW, is professor, Simmons College School of
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manuscript received: march 16, 2007
Revised: december 19, 2007
Accepted: January 22, 2008

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.

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

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Rudd and Bryan Clinical Application of Suicide Research

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

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Rudd and Bryan Clinical Application of Suicide Research

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

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Rudd and Bryan Clinical Application of Suicide Research

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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Conflict of Interest: The authors declare that the research was conducted in the

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