‘I Feel That There Is Someone Who Can Listen to Me’: A Mixed-Method Study on Asylum Seekers’ Experience of the Cultural Formulation Interview

Abstract

Asylum seekers face significant mental health difficulties. An assessment of cultural and contextual factors is necessary for a thorough evaluation of their mental illness. The Cultural Formulation Interview (CFI) can be a useful tool for this purpose, though further research is needed in diverse clinical settings and with varied populations to evaluate it as a cross-cultural assessment tool. Therefore, this study aims to map out asylum seekers’ experience of the CFI in a real-life clinical context, applying a mixed-method design. The CFI Debriefing Instrument for Patients (n = 63) data were quantitatively analysed. Semi-structured debriefing interviews (n = 61) underwent thematic framework analysis. The study demonstrates how asylum seekers rated the CFI moderately acceptable (6.74; SD: 3.24). Feasibility obtained a modest score (0.44; SD: 0.85). Clinical utility seemed to be perceived slightly higher (1.04; SD: 0.51). Thematic framework analysis identified facilitators such as the CFI's ability to ask relevant and understandable questions, stimulating in-depth conversations, new insights, and the patient–clinician relationship. However, barriers included the number and difficulty of the questions, the unclear benefit of the CFI, painful confrontation with the past and their suffering, and emotional distress. This study underscores asylum seekers’ nuanced experience of the CFI. Aspects proper to working with asylum seekers (e.g., impact of trauma, loss) must be considered when implementing the CFI. We formulate attention points to promote the use of the CFI as a tailored instrument to address asylum seekers’ mental health needs safely.

Keywords

asylum seekers Cultural Formulation Interview mental health experience mixed methods

Introduction

By the end of 2023, 110 million people had been forcibly displaced globally, including 6.9 million asylum seekers (UNHCR, 2024). Mental illness is widespread among asylum seekers, with prevalence rates reaching up to 30% for post-traumatic stress disorder (PTSD) and depressive disorder (Blackmore et al., 2020). Asylum seekers are confronted with a health care system that most often is embedded in a very different cultural context compared to their country of origin (Kleinman, 1977). Culturally divergent explanations of symptoms and treatment expectations between healthcare providers and patients undermine diagnostic accuracy. Diagnostic difficulties increase the risk that mental disorders among asylum seekers go undetected or are misdiagnosed. Incorrect diagnoses can lead to poor adherence to treatment, sub-optimal treatment, and, ultimately, even a lack of treatment. For an accurate assessment and management of asylum seekers’ mental health, it is necessary to carefully explore their illness narratives and cultural context (van Willigen, 2010).

To increase awareness of culture and context in psychiatric diagnoses, the American Psychiatric Association introduced the Cultural Formulation Interview (CFI) in the fifth edition of the DSM. The CFI facilitates a systematic assessment of cultural and contextual factors through a core set of 16 questions. If needed, an informant version and additional questions from 12 supplementary modules are available. This patient-centred approach allows for an individualized and non-stereotypical exploration of the role of culture and context in mental illness. Earlier research on the pilot version of the CFI shows how the instrument increases patient–clinician rapport, helps in diagnostic and treatment planning, fosters the exploration of patients’ illness narratives, and positively impacts medical communication (Jones-Lavallée et al., 2023). A multi-centre field trial proved the utility, feasibility, and acceptability of the CFI's pilot version (Lewis-Fernández et al., 2017).

Research on the patients’ experience of the final version of the CFI, as included in DSM-5-TR, is however limited (Jones-Lavallée et al., 2023). A Swedish study on the final version of the CFI highlights the interview as enhancing the patient-centeredness of psychiatric assessments (Wallin et al., 2020). Patients valued the CFI for acknowledging their cultural identities and personal illness narratives. The approach of curiosity and empowerment promoted by the CFI helped patients to feel dignified, hopeful, and more engaged in their future care (Lindberg et al., 2021). This approach appears especially crucial in encounters characterized by asymmetrical power positions, for example with migrants (Lindberg et al., 2021). Also, several difficulties were described, including a mismatch between the CFI questions and some clinicians’ understanding of culture, as well as its limited suitability for severely ill (e.g., psychotic) patients (Aggarwal et al., 2013; Ramírez Stege & Yarris, 2017). Caregivers worried that CFI questions about cultural identity and background would lead to perceptions of “alterity” and distance instead of alliance (Lindberg et al., 2022).

Although representative of the clinical reality, only one study describes the involvement of interpreters, which suggests that it could reduce the information elicited by the CFI (Skammeritz et al., 2020). In addition, only one study gained experience from using CFI with refugees. Even though the CFI's questions seemed to help explore refugee illness narratives, and refugees appreciated this exploration, some concrete problems arose in using the tool (Mika et al., 2015). Some CFI questions were too abstract for refugees, whose problems were strongly linked to the asylum context. They struggled to answer questions that required shifting between their home country and the host country in terms of space and time (Mika et al., 2015).

Despite asylum seekers’ specific mental health needs, and the potential of the CFI to offer a culturally sensitive approach to these needs, all current studies on the CFI excluded asylum seekers. For this reason, this study aims to address the knowledge gap on asylum seekers’ experience of the CFI in a real-life clinical context.

Methods

This study is part of a larger project on CFI use among asylum seekers, with a pre-published open-access protocol paper (Claus et al., 2023). Applying a multimethodological approach, this study aims to comprehensively map out asylum seekers’ experience of the CFI.

Participants and Procedure

First-line healthcare workers and social workers of the asylum centres referred asylum seekers in need of a psychiatric assessment and willing to participate in the research project. Only those capable of coherent verbal communication and able to provide written informed consent were included. An age criterion (15–29 years old) was set by the funder of this study. A pre-published protocol paper provides more details on the research project and study context (Claus et al., 2023). Following referral, the first author (LC) verified whether the participant met the inclusion criteria and completed the intake and consent procedure. All participants gave written informed consent, with the assistance of an interpreter when necessary. Following consent, the author LC conducted a clinical assessment of three interviews. First, the researcher-psychiatrist administered the DSM-5 CFI, the first (explanatory models), and the sixth (cultural identity) supplementary modules. In the second session, the 11th supplementary module (migrants and refugees) was administered, followed by a debriefing and a mental state examination. The final session included a structured assessment using screening questionnaires. It was decided in advance to use the different supplementary CFI modules to achieve a comprehensive cultural and contextual evaluation. All participants completed the core CFI and the supplementary CFI modules, followed by a CFI debriefing.

For a comprehensive debriefing of asylum seekers’ experiences with the CFI, this study utilizes two instruments. The first is the Debriefing Instrument for Patients (DIP), initially developed during the DSM-5 field trial and later adapted by Wallin and colleagues to enhance its relevance and comprehensibility (Wallin et al., 2020). This adapted version measures asylum seekers’ perception of the acceptability, feasibility, and utility of the core CFI (see Table 2). The DIP consists of nine questions, starting with an evaluation of the overall perception of the CFI questions on a visual analogue scale (VAS) from 1 (‘too personal’) to 10 (‘Good, helped me tell my story’). Two questions evaluate the perception of CFI's feasibility, and five questions the perception of CFI's clinical utility. These were scored from −2 (totally disagree) to 2 (totally agree). To conclude, participants were asked whether any of the CFI questions made them feel uncomfortable, and if yes, which questions. The second instrument is the CFI-debriefing interview as suggested by Muralidharan et al. (2017). This semi-structured questionnaire allowed mapping out of asylum seekers’ experiences of the importance of content, emotions, cognitions, utility, and distinctiveness during CFI administration. The full demographic characteristics of the participants are reported in Supplementary Table 1. The LC consequently conducted all CFI administrations and debriefing interviews. He received prior CFI training during a two-day training programme.

The authors confirm that all study procedures were executed according to the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures were approved by the University of Antwerp's ethics committee (BUN B3002022000005). Data were managed using REDCap, an electronic data capture tool (Harris et al., 2019). NVivo release 1.7.1 (Lumivero, 2020) has been used for the analysis of qualitative data, and SPSS version 29 (IBM SPSS Statistics: IBM Corp, 2023) for quantitative data.

Data Analysis

For the quantitative analyses, means and standard deviations were computed for each item of the DIP, as well as for the factors ‘clinical utility’ and ‘feasibility.’ The item ‘Took more time to share my perspective than I wanted’ was negatively worded and therefore scored in reverse. The internal consistency of the factor ‘clinical utility’ was evaluated resulting in a Cronbach's alpha of 0.61, which indicates questionable internal consistency of the 5-item factor ‘clinical utility.’ Removing the question ‘the CFI helped me explain what kind of help I would like’ would allow an increase of Cronbach's alpha to 0.66 though impede comparison with earlier literature. Due to the limited impact on the internal consistency, the questionnaire was left unchanged. The DIP scores of different clinical subgroups (gender, unaccompanied minors, history of psychosis) were compared and correlations with clinical parameters (age, Hamilton Depression Rating Scale, PTSD checklist for DSM-5 and Brief Symptom Inventory) were verified. A Shapiro-Wilk test showed a non-normal distribution, therefore non-parametric testing was applied (Mann-Whitney U test and Spearman Correlation).

Qualitative data consisted of the verbatim transcribed answers to the semi-structured CFI-debriefing interview. As this research is based on the collaborative process through which the narrative of the asylum seeker is brought forward—constructing meaning and knowledge through the interaction between the participant and the researcher-psychiatrist—it generally takes an epistemological social constructivist stance (Claus et al., 2023). This study applied a thematic framework analysis to analyse asylum seekers’ CFI experience qualitatively. The framework method proved suitable for evaluating health services, barriers, and facilitators and aims to facilitate comparison across cases (Gale et al., 2013). We applied the steps for a thematic framework analysis, as outlined by Gale et al. (2013). The CFI administration and debriefing interviews were audio-recorded and transcribed verbatim. As LC was present during the interview and participated in the transcription process, he was adequately familiarized with the research data. Author SVDA read through several debriefing interviews before engaging in the coding process. Given the lack of prior knowledge and our interest in asylum seekers’ comprehensive experience of the CFI, LC applied inductive and open coding to the first 20 transcripts. SVDA evaluated the initial coding process. LC and SVDA consequently grouped the codes into three main categories (instrument, individual, relation), which formed the working analytical framework. The framework intentionally differed from the debriefing interview's structure, to facilitate abstraction from the context and obtain a deeper level of understanding. LC then applied the working analytical framework to the subsequent transcripts. No new codes were identified after interview 38 (62%). The authors adapted and refined theme names within the framework throughout the analytical process. Then LC charted and analysed data using matrices for each category, identifying patterns and categorizing them into barriers and facilitators. During the interpretation stage, we examined variation within and between cases and categories, trying to go beyond descriptions of individual cases towards developing themes that offer a narrative that adequately represents the underlying data patterns. The most illustrative quotations were selected to represent the different themes. Randomly assigned identification numbers were linked to quotations to safeguard the anonymity of participants.

Results

General Characteristics of the Study Population

67 participants agreed to participate, of whom three dropped out during the CFI administration. One adult participant became suspicious of the CFI's personal questions and therefore no longer wanted to participate. Two minor participants interrupted their participation because they felt they had already answered enough questions. Additionally, one participant with severe mental illness didn’t complete the debriefing questionnaires. Finally, CFI debriefing data were collected for 63 participants. There was a loss of qualitative data for two participants (P26 and P63; 3.2% missing). Table 1 displays the participants’ characteristics.

Table 1.

Participant Characteristics (n = 63).

	N = 63	%
Gender − Female − Male	5 58	7.9 92.1
Unaccompanied minor (15–18 years old)	23	36.5
Interpreting assistance	58	92.1
Hospital or therapeutic service	12	19
Country of origin − Afghanistan − Palestine − Burundi − Iraq − Syria − Eritrea − Russia − Cameroon − Egypt − Gambia − Georgia − Ghana − Guinea − Macedonia − Morocco − Niger − Senegal − Somalia	34 6 3 3 2 2 2 1 1 1 1 1 1 1 1 1 1 1	53.9 9.5 4.7 4.7 3.1 3.1 3.1 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5
M.I.N.I. (n = 62) − Depressive disorder − PTSD − Psychotic disorder	50 44 26	79.4 69.8 41.3
	Mean	SD
Psychometric scales (n = 62) − GSI − HDRS-17 − PCL-5	2.3116.5355.53	0.906.8718.82
	Median	IQR
Age (years)	19	16-27

M.I.N.I.: M.I.N.I. International Neuropsychiatric Interview; PTSD: post-traumatic stress disorder; GSI: Global Severity Index; HDRS-17: 17-item Hamilton Depression Rating Scale; PCL-5: PTSD checklist for DSM 5; SD: standard deviation; IQR: inter-quartile range.

Five participants (7.9%) identified as women. Most participants (n = 58, 92.1%) needed the support of an interpreter. The participants’ median age was 19 years. About one-third of the participants were unaccompanied minors (n = 23; 26.5%). Twelve participants (19%) were temporarily residing in a hospital or therapeutic service at the time of the interviews. The participants’ countries of origin are mainly situated in the Middle Eastern region: Afghanistan (53.9%), Palestine (9.5%), Iraq (4.7%), and Syria (3.1%). Symptom severity scales of mental illness show high scores compared to a normal, non-clinical population, as reported in Table 1.

Quantitative Analyses: Acceptability, Feasibility, and Clinical Utility

In total, 63 participants completed the quantitative debriefing. Two participants didn’t understand DIP question 1 (‘How did you perceive the questions overall?’), impeding them from answering. Table 2 presents the results for the factors ‘acceptability,’ ‘feasibility,’ and ‘clinical utility,’ and for every DIP question separately. Asylum seekers’ mean rating on the VAS of the CFI's acceptability was 6.74 (SD: 3.24). Their mean rating of the CFI's feasibility was 0.44 (SD: 0.85), while their rating of the CFI's clinical utility was slightly but not significantly higher at 1.04 (SD: 0.51). The reverse-scored question on the time spent on CFI administration obtained the lowest score. Consequently, the time needed for the CFI had the most negative impact on their experience. About one-third (n = 21; 33.3%) of the participants reported that some of the CFI's questions made them feel uncomfortable.

Table 2.

Patients’ Ratings of the Revised Debriefing Instrument for Patients (DIP) (n = 63).

	Mean	SD
Acceptability:	6.74	3.24
− How did you perceive the questions overall? (n = 61) (VAS 0 to 10)	6.74	3.24
Feasibility:	0.44	0.85
− Were easy to understand (−2 to 2)	0.9	1.09
− Took more time to share my perspective than I wanted (R) (−2 to 2)	−0.02	1.19
Clinical utility:	1.04	0.51
− Helped me explain my main concerns (−2 to 2)	1.25	0.67
− Helped me communicate important aspects of my background, such as religious faith and/or culture (−2 to 2)	1.03	0.86
− Helped me understand how my background and current situation affect my problem (−2 to 2)	0.92	0.98
− Helped me explain what kind of help I would like (−2 to 2)	0.87	0.87
− Encouraged me to share important information that I might not have mentioned otherwise (−2 to 2)	1.13	0.61
	N	%
Did any of the questions make you feel uncomfortable? (yes)	21	33.3

SD: standard deviation; VAS: visual analogue scale; R: scored in reverse.

Of 19 participants who specified why they felt uncomfortable with the CFI's questions, most indicated that talking about the family (n = 6; 31.6%), the past (n = 5; 26.3%), or their homeland (n = 3; 15.8%) was difficult for them. Difficulty in understanding the CFI's questions (n = 4; 21.1%) was also mentioned, next to suffering from memories of violence by talking about it (n = 2; 10.5%) or feeling uncomfortable talking about their own (sexual) identity (n = 1; 5.3%). None of the comparisons between clinical subgroups or correlations with clinical parameters and DIP scores were significant, except for gender. Female participants rated question 3 (‘took more time than I wanted’) significantly lower (−1.40; CI: −2.08, −0.72) than male (mean 0.10; CI: −0.20,0.41) participants (p = 0.008), suggesting that they had more pronounced difficulty with the length of the interview. Consequently, feasibility turned out to be lower among female participants (−0.30 (CI: −0.85, 0.25) vs 0.51 (CI: 0.28, 0.73); p = 0.016). Participants of Afghan origin rated mean feasibility slightly higher than the other participants (0.62 (CI: 0.31, 0.93) vs 0.26 (CI: −0.05, 0.58)) (p = 0.03), losing significance after Bonferroni adjustment.

Qualitative Analysis

The thematic framework analysis of the open debriefing interviews focused on barriers and facilitators on three levels: the instrument, the individual, and the patient–clinician relationship. The first level covers information about asylum seekers’ perception of the CFI as an instrument (i.e., content of questions, value, duration …). The level of the individual focuses on their very personal experience of the CFI. The last area, the relational level, is made up of themes reflecting how the use of the CFI impacts asylum seekers’ perception of the therapeutic relationship.

Instrument's Level

The analysis showed three subthemes as facilitators on the instrumental level. Firstly, asylum seekers mentioned the CFI to ask appropriate questions. They experienced the CFI's questions as easily understandable and clearly formulated, imitating the course of a normal conversation, facing relevant and important topics: “What we talked about today and last time is all important to me” (participant 42). Secondly, asylum seekers found the CFI's specific focus useful to map out their story. They appreciated the CFI's particular attention to their background, life events, and difficult situations. They considered the CFI's questions useful to explain their past and their current problems and to find an appropriate solution. They felt that the CFI's attention to their difficulties was important given their high burden of distress, and thought that the CFI could contribute to better care for asylum seekers in the future: “Everything you’ve asked me is part of everything I’ve been through, so yes, I think it's useful. It can help to understand where the person is feeling bad [about], how you can help me as a doctor” (participant 43).

A third facilitator relates to their perception of the CFI's conversations as unique and in-depth. In contrast with prior experiences with caregivers, they experienced that the CFI offered them space to tell everything. They experienced the conversations as more focused than usual and felt they could discuss certain issues for the first time: “They were special questions, which I cannot otherwise talk to anyone about; (…) you formulate [questions] differently but still go a little deeper than the assistants” (participant 4).Two additional subthemes expressed the barriers in asylum seekers’ experience of the instrument. Firstly, asylum seekers expressed uncertainty about the added value of the CFI. Many found it difficult to articulate its benefits, struggled to remember its specificities, or were unsure how to feel about the process. In contrast to the aforementioned facilitators, some experienced how they had only been able to share a small part of their lives: “I don't know if that's going to help me help others understand how I feel; (…) your questions don’t help me, and they don’t affect my answers” (participant 18). A second and final barrier on the instrumental level concerns the difficult and time-consuming nature of the CFI's questions. The questions posed by the CFI are numerous, and asylum seekers experienced them as challenging, requiring much time and effort. For some, the similarity of the CFI approach to the asylum interview was troubling: “There were thousands of questions (…) Some of the questions were difficult because you asked those questions in a form of riddles” (participant 34).

Individual Level

The subthemes at the individual level fell into two facilitators and two barriers. A first facilitator relates to their experience that the CFI was helpful and could make them feel better.

Speaking about their difficulties felt good and was perceived as beneficial. Some mentioned how this led to an improvement in their complaints: “Telling you how I feel made me feel better afterwards (…) It also helped me unwind for a while; (…) I feel relieved when talking to you” (participant 53). Secondly, the CFI opened new perspectives for asylum seekers by helping them better understand their issues and bringing hope for improvement. The CFI-led conversations encouraged them to think about change and gave rise to a desire to continue talking: “I could dwell on some things about how to tackle them and deal with them. I strive to do certain things better” (participant 55).

They also mentioned barriers. Firstly, the CFI confronted asylum seekers with their suffering and painful memories, making it difficult to talk about past events and causing them to worry. Discussing family and home country issues was particularly challenging. Painful questions triggered distressing memories that many preferred to avoid.

I’ve been through a lot. To talk about it, it just hurts a lot; (…) Everything I’ve talked about is literally in my body right now. In my head, in my eyes, in my heart; (…) I feel I’m experiencing the same moment again; (…) Speaking about it, thinking about it, I think is harder than dying. (Participant 42)

Secondly, conversations on difficult topics took an emotional toll, requiring energy and strength, and often leaving asylum seekers feeling angry, sad, and burdened: “Talking about my problems, deep conversations, when I feel sad and oppressed. Then I just feel bad (…) The whole day I felt bad” (participant 32).

Relational Level

The analysis provided two subthemes as facilitators and one barrier on the relational level of asylum seekers’ CFI experience. Firstly, asylum seekers felt treated respectfully during the CFI. This respectful approach, without any forcefulness, allowed for openness and created a sense of trust. This contrasted with feelings of misunderstanding from previous caregivers, leading them to view the CFI-clinician as good and helpful:

You let me speak about things I didn’t want to bring up at first. You have a special way how you do it, it's as if you bring your hand into my head, and you look for things I want to talk about (…) I’m happy to have someone looking after me, (…) who is so attentive, patient and takes his time. (Participant 24)

Secondly, a CFI-guided encounter facilitated things to happen within a strong rapport with the clinician. It felt important for asylum seekers to share their individual experiences and have their cultural aspects understood by the clinician. Feeling heard made them feel better. The encounter allowed asylum seekers to unburden themselves, ‘empty their hearts,’ and find inner peace in the interaction. They perceived that the CFI-guided conversation enabled the clinician to empathize with their situation.

I feel a little emptier, a little calmer. I think I’m happy, in the sense of feeling like I’m not alone. I feel that there is someone who can listen to me. We talked about different moments, bad and difficult moments in my life. I had answers. I was in my head with that. I wanted to be able to share it with someone. (Participant 30)

However, confusion about the clinician's or the CFI's goals sometimes led to uncomfortable situations. Asylum seekers struggled to understand the clinician's thoughts or intentions and did not receive answers or advice during the CFI conversation. This sometimes made them feel forced to speak, adding to their discomfort: “During the conversation, I wondered: how do you see me, think about me, as someone powerless, a weak person? That makes me sad; (…) sometimes I felt obliged to tell everything” (participant 24).

Discussion

This study aimed to evaluate the CFI's acceptability, feasibility, and clinical utility for young asylum seekers and to explore their experiences with its administration. First, our quantitative analyses show how asylum seekers rated the CFI moderately acceptable. Feasibility obtained a modest score. To understand the low feasibility score regarding the time required, it 's important to note that this study utilized the core CFI with supplementary modules 1, 6, and 11, which takes longer than the core CFI alone. However, the supplementary modules allowed for in-depth conversations and a systematic focus on personal aspects, which asylum seekers appreciated. Clinical utility was perceived as slightly higher than feasibility, indicating the helpfulness of the interview. Regarding clinical utility, it 's noteworthy that debriefing questions with the lowest scores appeared to be the most linguistically difficult to understand. It can be hypothesized that a lack of understanding of these questions pushed them towards a more negative answer. Most participants who specified discomfort with the CFI's questions linked this to their personal difficulties (loss of family, homeland, and painful life events).

In comparison with the findings of this study, Wallin reported higher acceptability (mean 8.30 compared to 6.74 in this study), with fewer participants (14.5% instead of 33.3% in our study) noting discomfort (Wallin et al., 2020). Previous studies consistently obtained higher feasibility scores ranging from 0.9 (SD: 0.4) to 1.33 (SD: 0.57) compared to this study (0.44, SD: 0.85), as discussed below. However, asylum seekers’ perception of clinical utility (1.04, SD: 0.51) aligns with previous studies, which reported scores ranging from 0.9 (SD: 0.3) to 1.26 (SD: 0.31) (Lewis-Fernández et al., 2017; Paralikar et al., 2015; Rohlof et al., 2017; Wallin et al., 2020). While the time needed for the additional modules may account for some decrease in feasibility, the discrepancy underscores the importance of understanding more comprehensively asylum seekers’ subjective experiences with the CFI.

Second, the qualitative analysis of this study provides this more in-depth understanding of their experience on the instrument, individual, and relational level, as described below. At the instrument level, as in previous studies, asylum seekers appreciated the CFI for its appropriate and easily understandable questions that mirrored a normal conversation, facing important topics (Lewis-Fernández et al., 2017; Skammeritz et al., 2020). Asylum seekers valued the CFI's specific ability to map out their personal stories. In earlier research, patients describe the CFI questions as ‘eye-opening’ and a sign of recognition (Lindberg et al., 2021). In analogy with earlier research, our findings indicate that asylum seekers perceive the CFI's conversations as in-depth, due to the questions that prompt reflections on issues that patients hadn’t thought of or talked about before (Lindberg et al., 2021; Muralidharan et al., 2017). However, asylum seekers in our study expressed uncertainty about the instrument's perceived value, struggling to articulate its benefits. Furthermore, some participants in our study found the CFI's questions challenging and time-consuming, similar to earlier studies in which patients described the CFI's questions as difficult to answer or to understand (Skammeritz et al., 2020). Mika et al. (2015) found that refugees in Germany often misunderstood CFI questions due to their suffering being linked to the current difficult context, which complicates abstract questions jumping between the country of origin and the host country. They therefore recommend formulating questions as concretely as possible and specifying the context they refer to (Mika et al., 2015).

At the individual level, facilitators included the perceived helpfulness of speaking about their difficulties, which some asylum seekers felt led to an improvement in their complaints. The CFI also opened up new perspectives, helping them to better understand their issues and bringing hope for improvement. The aspect of gaining new perspectives (e.g., deeper realizations, conscience, hope, commitment to care) is a recurring theme in existing literature (Lindberg et al., 2021; Muralidharan et al., 2017; Skammeritz et al., 2020). Conversely, barriers at this level involved the difficulty of discussing adverse life events such as loss of family and homeland, which many preferred to avoid. The CFI conversation often took an emotional toll on asylum seekers. Also in earlier studies, participants reported feeling upset or less hopeful about their futures after the CFI encounters (Lewis-Fernández et al., 2017; Skammeritz et al., 2020). Although participants found the CFI valuable, they remarked that introspection could trigger uncomfortable emotional responses (Muralidharan et al., 2017). Mika et al. (2015) underscored the sensitivity of topics such as isolation and loss or distance of family among refugees, a difficulty also encountered in this study, which must be carefully considered in formulating CFI questions (Mika et al., 2015).

At the relational level, facilitators included the respectful treatment that asylum seekers perceived during the CFI, fostering openness and trust, and a strong rapport with the clinician, which made them feel heard, understood, and relieved. Different studies describe an improved patient–clinician rapport (Aggarwal et al., 2015; Wallin et al., 2020). Earlier research confirms that the CFI's person-centred approach can make participants feel validated and understood (Muralidharan et al., 2017). However, some of them also experienced confusion about the clinician's or the CFI's goals, which sometimes made asylum seekers feel forced to speak without receiving answers or advice. From a caregiver's perspective, Lindberg (2022) notes that professional insecurity about how to approach the cultural ‘other’ can be a barrier when asking about cultural backgrounds in the CFI (Lindberg et al., 2022). Together, these arguments contribute to the need for a clear outlining of the CFI and its purpose when used with minority patients with asymmetrical power positions in the patient–provider encounter (Lindberg et al., 2022).

The quantitative and qualitative findings of this study reveal a nuanced picture of how asylum seekers experience the CFI. Barriers highlight asylum seekers’ clear and manifest difficulties with the CFI, while facilitators demonstrate how the instrument is perceived as helpful. This nuanced experience of both difficulty and helpfulness is also reflected in the quite equivalent perception of feasibility and clinical utility. Additionally, feasibility might have been impaired due to the extra time needed for the supplementary modules used in this study and the high symptom severity among asylum seekers, indicating severe psychological distress. A previous Dutch study hypothesized that lower ratings on debriefing scales among patients with a migration background might be due to language barriers (Rohlof et al., 2017). The impact of limited education or low literacy on the CFI's experience is also unclear. In summary, this and earlier studies could identify several potential deficits in the structure and applicability of the CFI: uncertainty about its perceived value, its time-consuming questions that can be difficult to answer or understand, difficulty discussing adverse life events, and confusion about the interviewer's role and the instrument's goal (Lindberg et al., 2022; Mika et al., 2015; Muralidharan et al., 2017; Skammeritz et al., 2020). Furthermore, the findings of this study in particular highlight aspects unique to working with asylum seekers that must be considered when implementing the CFI.

Asylum seekers’ experience of the CFI seems strongly influenced by their complex history of trauma, experiences of loss, and need for recognition in a current context of instability and lack of perspective. Confrontation with painful memories and the current difficult situation were important barriers in their experience of the CFI. Realizing this, the feeling of doing more harm than good, and as such going against the ethical principle of ‘primum non nocere’ (non-maleficence), arose during this study. One could question whether a CFI-led conversation primarily risks causing harm by questioning these difficult memories and situations. However, since cultural formulation relies on engaging with an individual's life narrative—including potentially painful memories—this seems unavoidable to some extent. Therefore, the findings impose a reflection on the ethics and concrete application of the CFI in clinical encounters with asylum seekers.

Facing acts of extreme aggression and suffering often exceeds our capacity to process, absorb, and integrate, leading us to divert our attention or actively avoid thinking about it. Both individuals who experienced trauma and their surroundings engage in avoidance, attributing their silence to the ‘unspeakable’ nature of trauma (Van Gael, 2023). This extends to mental health contexts, where extreme trauma often goes unrecognized. Gerson describes the destruction of communication bonds and the resulting isolation when trauma is met with indifference (‘the dead third’) (Gerson, 2014). From this perspective, the CFI acts as a vital tool, offering asylum seekers a space to speak. The narrative process requires the caregiver to be an engaged witness, actively participating in the reconstruction of the patient's story (Gerson, 2014). An active, empathetic presence can help counteract the isolating effects of trauma and silence. Asylum seekers’ experience of not feeling alone anymore reflects this. The caregivers’ commitment to exactly know what happened helps them experience what ‘really happened to me’ (Gerson, 2014). This resonates with asylum seekers’ impression of gaining a better understanding of their problem through the CFI narrative.

Addressing trauma in asylum seekers also involves acknowledging the broader social and political contexts of their experiences. Recovery is hindered when there is no simultaneous recognition of social, political, and cultural difficulties (Varvin, 2018). Asylum seekers in this study appreciated the CFI's attention to their difficult situation, and how it enabled the clinician to empathize with their situation. In contrast, neutrality and emotional distance can evoke the echoes of a silent, ‘dead’ world, potentially causing iatrogenic harm and even retraumatization (Laub, 2017). In line with this, earlier work stresses the importance of engaging in a second-person position when handling the CFI with asylum seekers (Strand, 2024). It implies setting aside a detached observer role to actively engage with others, gaining direct access to their minds through shared, reciprocal interactions (Strand, 2024). Our findings highlight the importance of this second-person position in the CFI encounter by emphasizing the role of the clinician as an empathetic listener who makes participating asylum seekers feel heard and understood as a person and respectfully allows them to unburden themselves.

To conclude, Levinas’ phenomenology highlights the ethical nature of this face-to-face encounter, which is central to medical practice (Levinas, 1961). The moral obligation arising from this encounter emphasizes the importance of recognizing the patient's unique humanity, through hearing their narrative (Clifton-Soderstrom, 2003). One of the most pronounced findings of this study is how asylum seekers feel truly heard by the CFI, sometimes for the first time in their life. Creating space for narrative within medical practice honours the radical alterity of the patient, transforming the clinical encounter into a fundamentally ethical act of care (Clifton-Soderstrom, 2003).

Limitations

For the first time, research on the CFI has focused on asylum seekers’ experience of the CFI.

This study is among the few that has utilized certified interpreters as needed, enabling participants to express themselves in their native language (Skammeritz et al., 2020). While it may have resulted in translation difficulties or impacted the evolution of the therapeutic relationship, it also ensured the clinical representativeness of our findings. The sample consisted predominantly of males, who make up the majority of the asylum-seeking population (68% in 2023) in Belgium (CGVS, 2023). This study's focus on young adults and unaccompanied minors further increased their overrepresentation in the sample. As a consequence, the experiences of other genders were not well represented, which potentially limits the generalization of the quantitative findings. By including unaccompanied minors, the study included a large group of participants of Afghan origin. The ratio of Afghans versus other countries of origin was representative of the asylum-seeker population in Belgium at the time of the study (CGVS, 2023). Given that the prevalence of asylum seekers’ origins is context dependent, the findings possess a certain timeliness. Due to the limited sample size and heterogeneity, the power of our study is too low to examine differences in subgroups.

The multi-method study design allowed for a comprehensive mapping of asylum seekers’ experience of the CFI. There were very few missing data or dropouts, making their impact on the findings insignificant. As the debriefing interviews were conducted by the same caregiver as the CFI, this potentially introduced social desirability bias, which seems to be the main explanation for the slightly higher rating of feasibility by participants of Afghan origin. A larger research team, with a different researcher executing the debriefing interview, might have helped to overcome this possible source of bias. The very nuanced findings suggest that the study nevertheless obtained a full picture of the experience. This study is among the first to examine the clinical use of the supplementary CFI modules. We applied a fixed set of supplementary modules for methodological consistency, but the research design did not allow for an in-depth exploration of the specific experience of the supplementary modules, as we used the same debriefing instruments as for the core CFI. Consequently, their influence on participants’ experiences remains unclear, making comparisons with previous research difficult, as this focused mainly on the core CFI. For this reason, we tried to pay particular attention to the broader experience of cultural formulation as a method rather than of the specific questionnaires.

Several precautions have been taken to guarantee methodological quality (Claus et al., 2023). The study followed Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to report on the methods and results (Tong et al., 2007). A pre-published protocol paper aimed to ensure transparency and transferability (Claus et al., 2023). Interviews were conducted by the first author, a white cisgender male of Belgian origin, resident psychiatrist, psychodynamic psychotherapist, and PhD researcher, introduced as a medical doctor-researcher to the participants. This may have influenced participants’ experiences or created a sense of unequal power. The project's social constructivist stance acknowledges the potential introduction of personal bias. The research team, comprising clinical psychiatrists experienced in cultural psychiatry, is committed to advocating for the mental health of asylum seekers, which may have influenced their attitude towards the findings (Claus et al., 2023).

Implications

This study for the first time systematically evaluates asylum seekers’ experience of the CFI. The findings underscore asylum seekers’ nuanced experience of the CFI, with a comprehensive description of facilitators and barriers to using the CFI in mental healthcare with asylum seekers. Based on these findings, this study recommends formulating CFI questions concretely and specifically. The findings also emphasize the importance of clearly outlining the CFI's purpose and adopting a second-person approach by actively participating in the reconstruction of the asylum seekers’ story as an engaged witness. The nature of CFI questions can be overwhelming. Clinicians need to adjust the pace and complexity of the questions to accommodate the asylum seeker's emotional state. Moreover, discussions on sensitive topics like trauma, family issues, and homeland experiences often evoke emotional distress, requiring clinicians to conduct the CFI interview with caution. Providing opportunities for asylum seekers to steer the conversation and respecting their decisions regarding disclosure is crucial for maintaining trust and therapeutic rapport. Before starting the interview, it is advisable to inform the patient that they may interrupt or take breaks if necessary, and to assess any negative consequences during and after the interview.

The CFI can offer asylum seekers the space to give words to their suffering, and for the clinician to create a safe framework to do so, enabling an authentic encounter. In this encounter, clinicians must remain sensitive to asylum seekers’ pace and boundaries, acknowledging the potential for re-traumatization, a persistent challenge in administering the CFI with traumatized individuals. In this way, the CFI can be a tailored instrument to safely address the needs of asylum seekers that are often overlooked.

The findings of this study suggest that the CFI's questions could benefit from refinement to enhance their clarity and relevance. Engaging asylum seekers, refugees, and migrants in this process seems crucial to take into account their communication preferences and needs, and to ensure the tool is truly patient centred and allows for building connection with traumatized individuals. Additionally, evaluating interventions or support mechanisms to address the emotional toll experienced by asylum seekers during the CFI is of interest. These could include debriefing sessions, follow-up support, and strategies to help participants cope with distressing memories and emotions. Also, training on the appropriate use of the CFI preceding its application with patients is strongly recommended. Investigating the broader applicability of the CFI in various settings, beyond psychiatric assessments, could be useful. There are different contexts (primary care, social services, emergency departments …) where asylum seekers may seek support but often feel unheard. Finally, further research also needs to examine the effect of the CFI on clinical outcomes and to investigate implementation strategies to enhance the CFI's integration into routine clinical practice (Claus et al., 2023; Jones-Lavallée et al., 2023).

Conclusion

This mixed-method study highlights asylum seekers’ nuanced experience of the CFI. Quantitatively, the CFI demonstrated moderate acceptability and clinical utility, though feasibility was rated lower. Qualitative findings revealed that facilitators include the CFI's ability to foster in-depth conversations, the opportunity for asylum seekers to have their story heard, and a stronger patient–clinician relationship. Conversely, barriers include emotional distress and painful memories arising from the interview, questions that are abstract or difficult to understand, and the lack of clearly perceived benefits of the CFI. To address these barriers, the study offers concrete recommendations for using the CFI when working with asylum seekers. When the vulnerability of asylum seekers is taken into account, the study shows that the CFI may help systematically assess cultural and contextual factors relevant to young asylum seekers with mental health challenges.

Supplemental Material

sj-docx-1-tps-10.1177_13634615261418374 - Supplemental material for ‘I Feel That There Is Someone Who Can Listen to Me’: A Mixed-Method Study on Asylum Seekers’ Experience of the Cultural Formulation Interview

Supplemental material, sj-docx-1-tps-10.1177_13634615261418374 for ‘I Feel That There Is Someone Who Can Listen to Me’: A Mixed-Method Study on Asylum Seekers’ Experience of the Cultural Formulation Interview by Lukas Claus, Seline van den Ameele, Marianne Destoop, Karolien Dockx, Meryam Schouler-Ocak, Mario Braakman and Bernard Sabbe in Transcultural Psychiatry

Footnotes

Acknowledgements

We would like to express appreciation to those who enabled this project, especially the management and staff of St. Alexius Psychiatric Hospital, Mr Godfried Van Beuren in particular, the NGO ‘Brothers of Charity,’ the Federal Reception Network (Fedasil), and the Red Cross. We are also deeply thankful to our participants for their indispensable contributions.

ORCID iDs

Lukas Claus

Mario Braakman

Author Contributions

LC is the main researcher of this project, executed data analysis, and wrote the initial draft. SVDA, MD, and BS are supervisors of the research project. MS-O and MB are members of the research project's scientific board. SVDA reviewed the analysis and reworked the first version of the manuscript. BS, MD, MS-O, MB, and KD reviewed the revised version. All authors contributed to the article and approved the final version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project has received a grant (no. 2021-J5200810-219976) from the King Baudouin Foundation (Belgium), within the UCB Community Health Fund framework. The focus on young adults and unaccompanied minors (15–29 years old) in this study relates to the funding criteria set forth by the funder. Additional funding for the completion of this project was granted by the NGO ‘Evara’.

Conflicts of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

The data that support the findings of this study are available from the corresponding author, LC, upon reasonable request. The data are not publicly available for reasons of participants’ privacy.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Lukas Claus, MD, is a resident psychiatrist at the Vrije Universiteit Brussel, Brussels, Belgium, and a PhD researcher at the University of Antwerp, Belgium. His research focuses on the use of the Cultural Formulation Interview with asylum seekers. He is engaged in different care initiatives to promote cultural sensitivity in mental healthcare.

Seline van den Ameele, MD, PhD, is a psychiatrist working at the Department of Psychiatry and Medical Psychology, Brugmann University Hospital, Brussels, Belgium. She is affiliated with the postgraduate programme in integrative psychotherapy and obtained a doctoral degree at the University of Antwerp, Belgium. She teaches and researches transcultural psychiatry.

Marianne Destoop, MD, PhD, works as a psychiatrist in addiction care and in the mobile team at the Multiversum psychiatric hospital in Boechout, Belgium. In 2013, she obtained her PhD at the University of Antwerp, Belgium, and engaged as editor for the Dutch-Flemish Journal of Psychiatry (Tijdschrift voor Psychiatrie). Academically, she focuses on the research line ‘Urban Mental Health’ and teaches courses on addiction care and community-orientated care at the University of Antwerp, Belgium.

Karolien Dockx, MD, works as a psychiatrist at the Sint-Alexius psychiatric hospital in Grimbergen, Belgium, in a day treatment unit for personality and mood disorders. Within the hospital, she is the internship supervisor for the training of resident psychiatrists.

Meryam Schouler-Ocak, MD, PhD, works as a professor for Intercultural Psychiatry and Psychotherapy, and as a specialist for neurology, psychotherapy (particularly traumafocused psychotherapy), and EMDR therapy. She is chair of the Research Unit on Intercultural Migration and Care Research, Social Psychiatry at Charité Universitätsmedizin Berlin and Department of Psychiatry and Psychotherapy, Charité at St. Hedwig Hospital, Charité – Universitätsmedizin Berlin, Germany. Prof. Schouler-Ocak takes up leading roles in different international professional organizations. Her research interests focus on intercultural psychiatry and psychotherapy, trauma and trauma-related disorders, mental health and healthcare of immigrants, refugees, asylum seekers and ethnic minorities, suicidality, and diversity.

Mario Braakman is a psychiatrist and cultural anthropologist. He is professor of transcultural forensic psychiatry at Tilburg University, the Netherlands. He clinically works at the forensic psychiatric centre ‘de Rooyse Wissel,’ Oostrum, the Netherlands. His present research interest is cultural empathy. He is engaged in different professional organizations and is currently president of the World Association of Cultural Psychiatry. Em.

Bernard Sabbe, MD, PhD, is professor emeritus of psychiatry at the Faculty of Medicine and Health Sciences of the University of Antwerp, a full member of the Royal Academy of Medicine of Belgium, and vice-president of the Superior Health Council of Belgium. He was head of the University Psychiatric Centre Duffel, University Hospital Antwerp, and coordinator of CAPRI (Collaborative Antwerp Psychiatric Research Institute), a leading research centre in Flemish psychiatry.

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