The Cultural Interview in the Netherlands: the Cultural Formulation in your pocket

©Hans Rohlof, M.D. Psychiatrist and Head of Outpatient, Department Centrum '45 de Vonk, centre for traumatised refugees Westeinde 94 2211 XS Noordwijkerhout the Netherlands

Abstract
In the Netherlands immigrants from non Western origin form a fast growing part of the population. The need to get more information from their cultural background in mental health care is great. In our centre refugees from more than 50 countries come for psychiatric treatment. We provide them with treatment programs in a inpatient, day clinical and outpatient setting. In 2003 we had 450 new patients for 27 inpatient beds, 40 day clinical places, and an outpatient department of 18 therapists. Illness experience, idioms of distress and explanatory models are all very different among our patients. Somatisation and supernatural explanation of symptoms play an important role. Neurasthenia and hearing of voices of deceased relatives are prominent in our patients. In order to get a broader view on cultural background of symptomatology and possibilities for treatment we embraced the cultural formulation of diagnosis as published by the A.P.A. However, administration of the cultural formulation could be easier, we thought. Therefore we constructed a semi structured interview called the cultural interview. In a pilot study we tested this interview in 30 patients. The interview turned out to be feasible and was even regarded as a pleasant interview in the eyes of our patients. An English and German translation is constructed. A Spanish translation is in preparation. The interview gives advices for treatment concerning the cultural background of the patient. An English translation of the interview was published in a book in Dutch. This book contains also new visions on the Cultural Formulation.

Introduction
The Netherlands are a small and densely populated country in the North East of Europe. In a country of about 200 miles from North to South and 150 miles from East to West 16 million people are living. In the four large cities Amsterdam, Rotterdam, the Hague and Utrecht with their suburbs around 8 million people are living. This is called 'the city of Holland'. The Netherlands are a member of the European community since a long time. It is a kingdom, but the kings are submitted to the constitution and the parliament has the law making power. The country is wealthy and prosperous, mainly because of the presence of international companies, a strong and intensified agriculture, the traditional trade firms, the harbour in Rotterdam and the airport in Amsterdam, and the exploitation of natural gas. Since the Second World War there were no conflicts with other countries, nor were there tensions between population groups. Because of the prosperity the attraction of the Netherlands as a country to work in was great in the recent past. And because of the peaceful atmosphere a lot of refugees from war stricken parts of the world sought asylum. In the Netherlands the number of people who were born outside the country is therefore growing. Of the population of almost 16 million people the number of people who were born outside the country was 1.2 million in 1995, but 1.5 million in 2002. The number of children with at least one of the parents born outside the country was 1.2 in 1995, and 1.4 in 2002 (Source: Centraal Bureau voor de Statistiek, 2003). Responsible for this growth was the large influx of non Western immigrants and refugees. The number of people who were born in a Western country stayed stable at around half a million, and 800,000 for the second generation. Included in these last numbers were those born in Indonesia, since they were mostly people from Dutch origin living in a former colony. In a table we could show this as follows.

Table 1. Immigrants in the Netherlands in 2002, in thousands.

The four largest groups of non Western immigrants were Turks, Moroccans, and people from the former colonies Surinam and the Netherlands Antilles. The last country, a group of islands in the Caribbean, is still a part of the kingdom of the Netherlands, but has an own government. In table 2 there is a view of the four largest groups in 2002.

Table 2. Largest non Western population groups in 2002, in thousands.

The number of people with a refugee background is also growing. In 2002 there were 56.000 people who were born in former Yugoslavia, 36.000 people from Iraq, 23.000 from Iran, 28.000 from Afghanistan, 21.000 from Somalia, and 11.000 from Vietnam. These numbers are only about the legal inhabitants, and take not into account the number of asylum seekers and illegal people.
Because of these growing numbers we see also more patients from non Western origin in our mental health care institutions. In 1994 Centrum '45 which is an institution for treatment for people with traumatic experiences from the Second World War (1940-1945) decided to build a branch for the treatment of traumatised refugees. In that year the Bosnian War (1992-1995) was at his height, so many refugees from Bosnia came to Western Europe.
The department for the treatment of traumatised refugees is called 'de Vonk', which means the sparkle, which was the original name of his main building, constructed in 1923 for factory girls by a liberal spouse of a factory owner. In the centre there are 27 clinical beds, for refugees and also for their children, when they can not be abandoned, with a maximum of five children. There is also a day clinic with five different groups, whose participants come for one day in the week. This makes the number of day clinical chairs on 40. The outpatient units in Amsterdam and Noordwijkerhout give ambulant treatment on 400 new patients every year, with a total number of 5900 ambulant visits.
The patients in the centre are from more then 50 different countries. The largest numbers of patients are from Bosnia, the Middle East, the former Soviet Union republics, and West Africa. Surprisingly, people from Vietnam and Somalia are rarely seen in the clinic.

The Cultural Interview
In the centre 'de Vonk' the patients show all kind of symptoms which can be described as post traumatic. They experienced all kind of traumatic situations, like war, imprisonment, persecution, violence and torture, and loss of family members and belongings. The symptoms they show are part of the post traumatic stress disorder as described in DSM-IV, but are also of a different nature. Patients show delusions and hallucinations, which can be described to former traumatic events. Also, they have very often somatic complaints which could be explained because of psychological problems and traumatic experiences. These clinical impressions about the patients were confirmed by a research project in which a larger amount of post traumatic complaints were found then the DSM-IV describes (Ghane, 2003) Besides that clinicians in the centre have often problems with communication about symptoms and about treatment options. About half of the patients is not able to communicate in a Western language like English, French, German or Dutch: languages most clinicians in the Netherlands are able to speak. So the use of interpreters in the centre is needed. But even with interpreters miscommunication about information and about expectations in treatment are not rare.
More cultural information was also needed. The Cultural Formulation of DSM-IV (APA, 2000) seemed to be a good format to obtain more information about cultural identity, cultural illness explanations and treatment expectations, and cultural factors in support seeking and stress. This Cultural Formulation, as described in the case report in the journal Culture, Medicine and Psychiatry seemed to be an instrument which could be used at the end of a treatment. Wanted was an instrument which could implement the Cultural Formulation during the assessment procedure.
Therefore the so-called Cultural Interview was constructed (Rohlof et al., 2002). This is a structured interview of about 40 questions (see Appendix 1). With the completion of the interview one could make a Cultural Formulation of a given patient during the assessment procedure. A disadvantage could be that after completing the interview the clinician has the tendency to forget about the cultural aspects of the treatment. The Cultural Formulation begins with the Cultural Interview, but it does not end with it.

Experiences
After the construction of the interview, 30 patients were interviewed. The experiences with the interview were presented elsewhere (Loevy et al, 2000). The interview turned out to be feasible. It took about one and a half hour time, depending on the patient, the interviewer and the presence of an interpreter. The interview was even considered as pleasant by most patients, since they were able to talk about good things in their past, and not about the bad experiences or their symptoms. The interview asked about events, behaviours and attitudes in the culture of origin, and thus denied somehow the possibility that the patients lived in a new culture: the immigrant culture in the Netherlands. However, that aspect seemed to be less important.
With the interview it was possible to gather much information from the cultural background of the patient. It was enough to make a Cultural Formulation of the patient. Several findings were:
1. Beginning therapists tend to take the interview as a more rigid structure then experienced therapists. The latter ones tend to ask their own questions, which leads in some cases to the gathering of less relevant data.
2. The structure of the interview with starting to ask about the cultural identity (like in the Cultural Formulation) makes the interviewee feel at ease. The questions about the cultural backgrounds of the complaints were more difficult and less pleasant to answer.
3. It is nice to give the patient examples from the Dutch culture. Asking about the most important thing in life can be illustrated by telling about the habit to have a wall plate with the family maxim at the chimney.
4. In the interview questions about conflicts with cultural things were avoided. This is something to keep in mind. Sometimes patients can have conflicts with for instance their Muslim background.
5. The interview proved to be important in the process to build a right image of the patient. For clinicians it is common to make a stereotypical image of a patient from the first look. The interview can help to have a more detailed image.
6. The interview is better to be taken by a third person, not the own therapist. This improves the objectivity of the interview
(Rohlof & Ghane, 2003)
In the mean time, the third improved edition of the Cultural Interview in Dutch has been made. Translations into English and German are made, and a translation into Spanish is in preparation. The interview is used in mental health care, in general health care, and in research. The interview needs more scientific elaboration, like the clustering of questions, and perhaps also a more quantitative approach.
It increased the interest in the Cultural Formulation in the Netherlands.

Culture, Classification and Diagnosis
In 2000, the writers Ria Borra, Rob van Dijk and Hans Rohlof decided to publish a book with chapters about transcultural diagnostics, about the cultural formulation and the cultural interview. They decided to ask other authors to write a case history according the Cultural Formulation. This resulted in a book (Borra et al, 2002) with three theoretical chapters, seventeen case histories, a concluding chapter, and the text of the cultural interview. The book was called Culture, Classification and Diagnosis in order to illustrate that a classification according DSM-IV is far from a real diagnosis, and that culture is a missing link in the case of classification. In the Netherlands the book was greeted as a welcomed guidebook for transcultural cases.
In the concluding chapter some comments were made on the Cultural Formulation. Gaps in the Cultural Formulation were described. The aspects of communicating in different languages and the use and role of interpreters are not mentioned. Next to this, there is not much attention on the own culture of mental health care: what does the patient think about talking and insight oriented therapies, for example. Also, the interest of subcultures in the culture of origin should be stressed more. Culture is not static, but more dynamic, especially in recent migrants, who tend to take cultural behaviour and attitudes from the host country or from the migrant culture in the host country very quickly. Finally, there should not be any overemphasis on culture. Culture does not account for all differences between population groups. Social and economic factors are also important. There are also differences in power and in accessibility to health care systems. Stigmatisation plays also a big role.
In 2003, a conference took place to introduce the book into Dutch mental health care. From the lectures of this conference a new book was published (van Dijk et al, 2003).
The discussion about cultural factors in mental health care did not end. New plans arise. The Section on Transcultural Psychiatry of the Netherlands Psychiatric Association, which was founded in 2003, sees it as an important task to comment on the basic concepts in psychiatry, in assessment, therapy, and research. One of his activities in 2003 was to comment on the new protocol for the assessment procedure, published by the Netherlands Psychiatric Association. At the moment a small working group is busy with constructing a new format for assessment in psychiatry, with attention to cultural data. Work in this field proceeds. To be continued.

Literature
Borra, R., van Dijk. R.& Rohlof, H. (ed.) (2002). Cultuur, classificatie en diagnose. Bohn, Stafleu van Loghum, Houten.
Centraal Bureau voor de Statistiek (2002). Allochtonen in Nederland. CBS, Voorburg/Heerlen.
Ghane, S. (2003). An exploration of posttraumatic reactions among treatment-seeking refugees. University of Amsterdam, Amsterdam.
Loevy, N, Rohlof, H., & Sassen, L. (2000). Een gestructureerd interview voor de culturele formulering van de DSM-IV bij vluchtelingen. Lecture presented on the conference Cultuur en Gezondheid, Amsterdam.
Rohlof, H., Loevy, N., Sassen, L & Helmich, S. (2002). The cultural interview. In: Borra, R., van Dijk. R.& Rohlof, H. (ed.). Cultuur, classificatie en diagnose. Bohn, Stafleu van Loghum, Houten.
Rohlof, H. & Ghane, S. (2003). Het culturele interview. In: Van Dijk, R. & Sönmez, N. (ed.). Cultuursensitief werken met DSM-IV. Mikado, Rotterdam.
Van Dijk, R. & Sönmez, N. (ed.) (2003). Cultuursensitief werken met DSM-IV. Mikado, Rotterdam.
Internet:
www.rohlof.nl
www.centrum45.nl
www.mikado-ggz.nl

Appendix 1. The Cultural Formulation interview English version
Hans Rohlof, Noa Loevy, Lineke Sassen & Stephanie Helmich
Summary and case history Filled in using the dossier before the interview
1. Biography (personal and social details)
2. History of current symptoms
3. Earlier treatments
4. Psychiatric illness within the family
5. Course of illness Introduction
Aim: explaining the interview and setting the tone "People from all over the world come to our clinic. Every country and every culture has its own way of life. You only really notice when you leave your own country and go to live in a foreign country. People look different, speak another language, behave and express themselves in different ways. We can sometimes get the feeling that we are not understood. Have you ever had that feeling? [If yes, listen briefly to explanation - "we will deal with this later on in the interview". If no, "Maybe you will understand what I mean when we discuss it later."] Problems in communication are sometimes partly the result of a lack of knowledge of cultural differences. Since we would like to help you as best we can, it is important for us to understand something of your country and your culture. By this we mean your way of life, which days you celebrate, what it means for you to be ill etc. I will now ask you a few questions about your culture and your symptoms".
A. Cultural identity of the individual · What is your native language? . What language do you speak at home/ with your friends/ in your dreams? · What other language(s) do you speak? · How well do you speak Dutch? How does it feel to always have to speak Dutch? Does it sometimes cause problems? · To which ethnic group do you officially belong? Do you feel that you do belong to this ethnic group, or to another one? Does this ever change? (E.g. do you always feel that you are ..... or sometimes something else?) · Do you miss other people having the same cultural background as yourself? (If yes:) Explain/ Why? · What aspects of your culture are most important to you. (E.g. family structures, norms and values, feast days, faith...) Do you have children? · (If they have children) Do you bring up your children in the same way that you were brought up? Explain. · (If no children:) Would you bring up your children in the same way? Explain. · To what extent can you follow your culture's way of life here in the Netherlands? · Are their aspects of your culture that bother you are that you find less attractive? · Do you feel involved with Dutch culture (E.g. do you interact much with Dutch people, do you go to Dutch social events, do you read Dutch literature, are you interested in how thing work in Dutch society, are there things in the Dutch culture which you are adopting.....)? · If so, what aspects of Dutch culture do you like, and what aspects bother you?
B. Cultural explanations of the individual's illness
(Record explanation in individual's native language) Now, about your symptoms, · What are your worst symptoms? What do you call them in yor own language? · How do you think your symptoms started? (If only single answer: do you think that there are alternative/more explanations for your symptoms?) · How do your friends, family and those around you explain your symptoms? · How would people of your culture explain your symptoms? · Do you feel understood by your friends, family and those around you? · Have you felt up to now that the staff here understand you? Would you expect them to? · If someone in your home community was sick, or had roughly the same symptoms as you, how would those around them try to help (e.g. pray for them, leave them to rest, care for them)? · Are you being cared for in that way now? · Do people where you come from sometimes make use of alternative, native or faith healers, or do people go to a normal doctor or hospital? · What kind of help have you had up to now for your symptoms (both normal and alternative)? What helped most? · What kind of treatment would you like to receive now? What would you personally prefer? ( Examples: Talking about events in the past, adapting to the present, make plans for the future, talking about your emotions, receive advice, exercises, medecines,...)
C. Cultural factors in psychosocial surroundings and in functioning.
Now, let's discuss your daily life here rather than your daily life in your native country · What is your current situation - are you married, do you have a family here? · What is your position in you family? Is this different to the situation in your country of orgin? Explain. · Is there someone in your family who people go to for advice? · If married: How is your relationship with your wife? Is this different to what it was in your country of origin? Explain. · If has a family? How is your relationship with your family? Is this different to what it was in your country of origin? Explain. · Have there been important changes in your social position in recent years? If yes:what does this mean for you? · If you have a practical problem, such as something you do not understand (e.g. train journeys, the immigration service, a letter from your lawyer) whom would you ask about it? From whom would you get the information? · If you had (emotional) difficulties in your own country, what did you do? To whom did you go? · Is there someone in the Netherlands from whom you receive (emotional) support (e.g. when you are sad)? Is this person family of yours? How often do you make use of this opportunity? · Is there someone in the Netherlands with whom you talk about your symptoms and traumatic experiences? If yes: Why him/ her? Is there someone you would like to talk to? Explain. Some people are greatly strengthened by their faith, · Are you religious? · Do you pray? How often? · Do you feel that prayer helps you? In what way? · Has your faith changed since the experiences you had? · Do you still pray as often as you did? · Do your prayers help you as much as they did? · Do you go to a place of worship (church, mosque etc) in the Netherlands? Do you always go to the same one? How often do you go? · Do you know the people there? · Do those people help you? Is there someone in particular who helps you? In what way do they do that?
D. Cultural elements in the relationship between the individual and the carer · To which social class did you belong in your country of origin? Did you live in a town or in the countryside? What education have you had? · Some people consider clinical staff to be their equals, sometimes even their friends. Others feel that the staff are above them, or beneath them. How do you see this? Do you that the medical staff and social workers are equal to you, beneath you or above you? When they advise something or prescribe medicines do you feel that you must take the advice or use the medicines? · If you had a free choice in selecting the personnel treating you, would you prefer male or female personnel? (As a choice: ) Why? (trust, shame, more likely to understand, easier to express yourself...) · If you had a free choice in selecting the personnel treating you, would you prefer personnel with a similar cultural background to yourself, or do you not think that this matters? (As a choice: ) Why? (trust, shame, more likely to understand, easier to express yourself...) · How do you feel about the fact that you don't receive therapy in your own language? Would you like to be given therapy in your own language? Would it help you feel that you were being understood properly? · If an interpreter is being used: How does it feel to work with an interpreter? If you could choose would you prefer a male or a female interpreter
This is the end of the interview. Thank you very much indeed, I personally found it very interesting to learn about how these things work outside the Netherlands and I hope that we can use what you have told me to understand and help you better. Is there anything else that has not been mentioned in this discussion an which you would like to tell me about? To be completed by interviewer after interview (optional, some matters will only become clear during the course of the treatment): · Communication problems experienced within the patient's own language (use of terms/concepts and motivation/interest · Extent to which symptoms have a cultural meaning for the patient · To what extent is the patient prepared to engage in a working relationship with the therapist? · Degree of closeness (personal contact) · Pathology or otherwise of behaviour.
E. Observations during the interview What was the contact with the client like? What kind of impression did he/she make? Record other notable issues from the conversation
F. Summary Summary of the most important issues raised during the interview G. Advice for further treatment Possible problems in the area of cultures which could be an obstacle communicating with patiënt and specifying the diagnosis and the treatment. At the same time things can be noted which can be looked at in treatment.

Research version ©NL&LS 04/05/2000: second version ©NL&HRO 29/08/2000: third version ©SH&HRO 08/10/2001; copying or reproduction without written permission is not allowed. permission to be asked to: Hans Rohlof

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