Adapting the Cultural Formulation Interview for the Military

Overall, 7% of the U.S. population has served in the military or is currently on active duty, and one in five Americans has a family member who served (1). Active duty members are more likely to experience mental disorders compared with their civilian peers (2–4), and rates of suicide among active duty members have doubled since the 1990s (5)—with most veteran suicides occurring outside of the Veterans Affairs (VA) health care system. Culturally informed care appears to be critical to successful treatment of service members (6), and assessment for military service is a key “unasked question” of patients in contemporary medicine (7).

Civilian providers frequently lack the knowledge and skills to assess military culture (8), and few training programs include such preparation (9). This gap may increase because the VA MISSION Act permits veterans to seek health care within the civilian sector (10) and military branches begin embedding civilian providers (11). Although a possible solution might be to rely more heavily on military or veteran physicians to treat service members, there is evidence that even these providers may need to enhance their awareness of military culture (8).

Taking a military history is now a codable aspect of care; several training sessions have been created to improve awareness of military culture (12, 13), and the VA has developed a pragmatic pocket card that provides culturally relevant questions (14). Although useful, these tools fall short of capturing the dynamic nature of culture. Culture influences every aspect of patient care, such as the communication practices through which patients narrate distress (15), the patterning of symptoms (16), the diagnostic models used to interpret symptoms (17), and perceptions of acceptable treatments (18). Additionally, although military culture is highly prescribed and defined (19, 20), service members’ own cultural backgrounds are diverse (e.g., geographically, ethnoracially, economically, and religiously) (21), and, although military acculturation is typically quite high, it can vary widely on the basis of personal experiences (22). Furthermore, service members may view a provider’s lack of expertise in military culture as a more significant treatment barrier than their own military culture concerns (23).

In 2013, the American Psychiatric Association published the DSM-5 (24), which included the Cultural Formulation Interview (CFI), a 16-question protocol with instructions and additional probing questions that clinicians could use for cultural assessments, regardless of patient or provider characteristics (25). DSM-5 also included 12 supplemental modules to expand the basic assessment for specific populations (e.g., children and adolescents or older adults). Neither a military version of the core CFI nor a military supplemental module was created, and the DSM-5 currently does not specify methods for developing another version of the CFI or additional supplemental modules (26). In this article, we sought to determine whether the CFI sufficiently addresses military culture. To make the CFI applicable to other populations, we present a process for systematically reviewing the literature, defining critical domains for cultural assessment, comparing those domains with the CFI, and suggesting modifications to the CFI as needed.

Methods

A team of researchers was recruited that included members from inside (E.G.M., R.B.D., M.C.H., W.L.B., C.C.E.) and outside (N.K.A., F.G.L., R.L.F.) the military. Authors from outside the military were selected for their critical roles in designing the core CFI (26). Active duty (E.G.M., M.C.H.), reserve (R.B.D.), and veteran (W.L.B. and C.C.E.) members participated. A balance of service branches—namely, the Army (C.C.E.), Air Force (E.G.M., W.L.B.), and Navy (R.B.D. and M.C.H.)—was prioritized from the outset.

The team first defined military culture. Although this term could refer solely to the culture of active duty military members, previous research has shown that the core values of active duty military culture persist for veterans (27) and permeate the lives of family members (28). We then set out to determine what aspects of military culture affect clinical care. We searched the PubMed (Medline), PsycINFO, EMBASE, Scopus, and Web of Science databases for articles by using key words and controlled vocabulary terms. (A list of terms is presented in online supplement 1 to this article.) Databases were initially searched on April 18, 2017, and updated on September 17, 2020, to cover additional studies published since the initial search. Research articles, reviews, editorials, books, and chapters published in the past 10 years were included in this study to capture contemporary recommendations. Only English-language articles were reviewed. Titles and abstracts were independently reviewed by two authors (E.G.M., R.B.D.) for two exclusion criteria: published works that were not specific to military culture or those that lacked guidance specific to a clinical setting. When the two authors disagreed on an exclusion, the senior author (R.L.F.) reconciled the differences.

The research team created a data-charting form (29) and randomly divided the articles into three groups. There were two reviewers per group, and each reviewer independently summarized every article. A balance of military experience was maintained for each reviewer pair. Reviewers discussed differences until consensus was achieved. If two reviewers could not reach consensus, a third reviewer summarized the article independently to help determine which aspects of military culture were described as affecting care. In addition to general summaries, questions that were explicitly proposed as helpful to assessment (e.g., “Have you or someone in your immediate family served in the military?”) (30) were abstracted verbatim.

Through content analysis (31), two authors (E.G.M., R.B.D.) inductively coded the summaries and quotations into a hierarchical framework of military culture domains. This task was accomplished by iteratively coding material until no new codes were found. Throughout this process, coding audits were completed with all authors by means of tracking sheets. In addition to organizing the codes into cultural domains, we recorded the frequency of each domain in the literature.

The CFI components (introduction and 16 questions) were cross-analyzed with the cultural domains found in the previous step. Six authors (E.G.M., R.B.D., M.C.H., W.L.B., F.G.L., R.L.F.) labeled each CFI component by using the following categories: the CFI component is unrelated or not applicable to this domain, the CFI component is likely to elicit this domain without additional guidance, and the CFI component is unlikely to elicit this domain without additional guidance.

If a CFI component did not relate or apply to any military culture domain (category A) or was likely to elicit all related military culture domains (category B), no change was recommended. Conversely, if a CFI component required additional guidance for a military culture domain (category C), relevant edits to instructions or questions or new probes were recommended. Specifically, if a component implicitly referenced a military culture domain, explicit instructions were provided. If a question required specific military culture language, this language was added. If more than a few words were needed to explore a military culture domain, a probing question was recommended.

On the basis of these results, a military version of the core CFI was created. This draft of the military CFI was sent for independent review to the two authors who did not participate in the cross-analysis or the drafting process: a military culture subject matter expert (C.C.E.) and a cultural competence–CFI expert (N.K.A.). Their recommendations were incorporated into a final version after consensus with the research team.

Results

Sixty-three publications were identified for inclusion in this study (see online supplement 1) and iteratively coded into a hierarchical set of 22 military culture domains (Table 1). (Mapping of domains to specific articles is provided in online supplement 1.) The most common independent domain was the concept of a military-civilian gap (N=35 of 63 publications, 56%). This domain captured the perception that civilian providers do not understand the military. Another common domain was military language (N=12, 19%)—words and meanings that civilians do not generally know. Sample clinical questions were found for all but three domains: order, structure, and privacy (see online supplement 1).

The most common collection of domains fell into the category of military values (N=39, 62%), including service, competence, sacrifice, mission, and collectivism. The next most common collection of domains, the category of events (N=38, 60%), related to unique themes such as deployments, reintegration, and trauma. The reintegration domain referred to returning from a deployment or leaving the military to rejoin civilian society. The trauma domain included not only combat-related violence but also exposure to workplace-based accidents and natural disasters. Another collection of domains, termed structural organization (N=28, 44%), focused on cultural orientations of hierarchy, order, and structure to military life and the difficulty in navigating life without clear boundaries or guidance. Organization into military subcultures, or structural differentiation (N=23, 37%), included branch of service, generations (when a person served, to include the difference between active duty members and veterans), occupation in the military, and the difference between active duty and reserve status.

A separate collection of domains, individual social variables (N=27, 43%), included forms of social belonging that could compete with other aspects of military culture. This collection included cultural aspects of family, gender, and sexuality. As an example of how these domains competed with other aspects of military culture, several studies reported that, whereas some service members may rely on military service as a method to actualize a perceived “masculinity” or “masculine culture,” others may perceive military “masculinity” or “hypermasculinity” as conflicting with “feminine” culture (32–34). Similarly, some articles described family life as what military service members sacrifice because of separation resulting from deployments or other service obligations, inferring that a cultural commitment to family can be at odds with military culture. Other articles referred to family as sharing in the sacrifice, concluding that military family members share some of the same cultural priorities with those who served (35, 36). The final collection of domains, barriers to care (N=22, 35%), manifested in two ways: as a perception that there was cultural stigma associated with seeking care and a lack of privacy.

Cross-analysis of the content of the core CFI with these 22 military culture domains revealed two CFI questions that were unrelated (category A) to any military culture domains (question 1, “What brings you here today?” and question 11, “Sometimes people have various ways of dealing with problems like [PROBLEM]. What have you done on your own to cope with your [PROBLEM]?”). One question (i.e., question 13, “Has anything prevented you from getting the help you need?”) adequately elicited five military culture domains (language, privacy, stigma, sexuality, and gender) without requiring additional guidance (category B) but failed to fully elicit four other military domains (service, competence, sacrifice, and collectivism) (category C). The introduction and the remaining 14 core CFI questions required additional guidance. (Specifics for each domain and CFI component are available in online supplement 1.)

Given the overlap between the core CFI questions and the military culture domains, we determined that a military version of the core CFI would be more integrative than a separate military culture supplement. Integrating military details into the core CFI also appeared to make it easier for providers to focus on other cultural identities that their military patients might be prioritizing. Additional guidance was drafted for the core CFI introduction and all questions other than questions 1 and 11. Additional instructions were recommended for the introduction and 12 CFI questions. For example, core CFI question 3, “What troubles you most about your problem?” implicitly related to 21 military culture domains, so the following instructions were added: “For military members, consider impacts on competence, ability to sacrifice, mission, deployments, reintegration, and privacy. If [PROBLEM] relates to sexuality or gender, consider relationship to military membership.” For five of the CFI questions, the question itself was unlikely to elicit the military culture domain because of limitations in wording. For example, CFI question 7, “Are there any kinds of stresses that make your [PROBLEM] worse, such as difficulties with money or family problems?” is unlikely to prompt a patient to consider their military culture, so an additional clause, “or difficulties with your/their military service,” was added to the end of the question. For 10 CFI questions, an additional military-specific probing question was required to explore the military culture domain. For example, core CFI question 3 benefited from an additional probe: “How is this influenced by your/their military service, if at all?” These additional probes were informed by the recommended clinical questions found in the literature (see online supplement 1). (The final military veteran version of the core CFI is available in the online supplement 2.)

Discussion

The CFI provides clinicians with an evidence-based, person-centered method for assessing cultural influences on illness experience and expectations of care. Through a systematic comparison of the core CFI with contemporary literature on clinical aspects of military culture, this review revealed that aspects of military culture were missing or unclear in the core CFI. On the basis of these findings, and in collaboration with several CFI developers (N.K.A., F.G.L., R.L.F.), we proposed minimal edits to improve the applicability of the CFI to the military. Our methodology for evaluating military culture provides an overall process for determining the applicability of the CFI to other groups and, if indicated, a method for tailoring the CFI to them.

The most common domain of military culture in the studies reviewed was a perceived gap in understanding between civilian clinicians and military members. Although many subgroups experience being misunderstood, the assumption that being misunderstood is a defining element of military culture merits further study, especially as more veterans seek care within the civilian health sector. The second most common defining aspect of military culture was a shared set of values. The fact that our findings for this domain overlap with established and expected military values was reassuring, indicating that the clinical literature aligned with intended cultural priorities for military patients. At the same time, the realization that the intentional and explicit values crafted by the military mapped to domains that could negatively affect a patient’s perception of their illness and treatment is important to consider. Military values are not inherently harmful; however, ideals such as service and sacrifice do appear to have the potential to negatively affect how military patients perceive illness and treatment. Although simply attributing a person’s illness or treatment difficulties to military service would likely undermine the therapeutic alliance, the CFI’s approach of using normalizing language and approaching topics through open questions rather than assumptions (25) should help providers navigate these potentially difficult conversations.

Another finding was that cultural identities that include social constructs such as gender, sexuality, and family appeared to potentially conflict with other military culture domains. These overlapping cultural domains reveal an intersectionality (37) of the multiple cultural identities that may more effectively capture the way that military members, veterans, and their families understand their illnesses and care. For some, nonmilitary aspects of cultural identity and their military identity is perceived as complementary. For example, a heterosexual man whose family joins him in the sacrifice related to service might readily discuss nonmilitary aspects of identity within the context of the military. Conversely, patients who view their nonmilitary cultural identities as being at odds with their military service may benefit from the core CFI’s approach to exploring culture through nonleading, open-ended questions. In both situations, it may be best to explore a patient’s various cultural perspectives separately before attempting to understand how the intersecting identities interact.

One final observation is that the constructs of ethnicity and race, or racialization, did not emerge from the reviewed articles as key components of military culture. These constructs also did not appear to be explicitly at odds with military culture as we found with aspects of gender, sexuality, and family. This finding was confirmed by explicitly re-reviewing the included articles for these two constructs. Although the apparent absence of the race-ethnicity construct in military culture may reflect a limitation of the current literature, it may also support evidence that the military has frequently been a leader in establishing ethnic and racial equality (38). More importantly, it underscores the importance of considering the intersectionality of a patient’s cultural identity. Although ethnicity and race, or racialization, may not have an explicit relationship with military culture, a person’s perception of their illness or treatment is likely to be influenced by both their ethnic or racial identity and their military identity. This further underscores the value of using open-ended questions to explore cultural identity in the CFI; the patient is able to spontaneously report multiple aspects of identity that are relevant to the presenting problem, including race-ethnicity.

This study had two key limitations. First, we used published studies for our literature review. It is possible that the gray literature reports other domains important to military culture. Furthermore, as the literature on this topic expands and matures, it is possible that new domains will emerge, necessitating updates to the definition of military culture. For example, as awareness of structural racism’s impact on health care disparities continues to expand (39), an explicit relationship of ethnicity and race with military membership might emerge. The second limitation was that the authors with military experience were all commissioned medical corps officers. Inclusion of enlisted personnel, individuals with previous enlisted experience, or members who served outside of the medical corps should be considered in future work.

Conclusions

The original, open-ended approach of the core CFI can elicit useful culture-related information from patients with a variety of backgrounds. The core CFI is likely to satisfy providers looking for a tool that will cover most clinical situations. However, as in all aspects of clinical medicine, a focused approach is sometimes needed to gather necessary information. For instance, although cognitive screening tools might be sufficient for most patients, they are often wanting when assessing patients with complex traumatic brain injury. Similarly, for providers who do not routinely work with military patients or are not familiar with military culture, it may be beneficial to use the military version of the CFI to uncover specific military culture domains. Other providers who routinely serve a specific population may choose to follow a similar approach by comparing the findings of a systematic literature review with those of the core CFI to determine whether developing a specific version of the CFI is warranted.

Understanding the impact that military identity could have on patient care is paramount at a time when military service members, veterans, and their family members are increasingly seeking care from civilian providers. The military version of the CFI operationalizes the available research on clinical aspects of military culture into a cohesive approach to interviewing military patients that can be integrated into any clinical encounter and may improve our understanding of military patients. Additional work using qualitative interviews of active duty members, veterans, and their families might uncover other cultural domains. Future study of clinical outcomes associated with the use of this version of the core CFI, especially in comparison with the original version, is warranted. As the rates of suicide and mental illness continue to rise in the military, having a version of the CFI that is specifically calibrated to assess unique aspects of military culture may prove invaluable.