Response

We read with interest the recent editorial by Hussain and Kar titled ‘Beyond the biopsychosocial: why psychiatry needs anthropology’,^{Reference Hussain and Kar1} proposing to extend the biopsychosocial model with an anthropological integration.

Although we find this intellectually compelling, it has previously been difficult to practically implement cultural frameworks such as the DSM-5 Cultural Formulation Interview (CFI), often due to time pressures and lack of standardisation.^{Reference Aggarwal, Nicasio, DeSilva and Boiler2} We therefore need to ensure that use of Kleinman’s questions^{Reference Kleinman, Eisenberg and Good3} or DSM-5 CFI does not become another tick-box exercise, and suggest that a two-tiered model may reconcile aspiration with practicality: brief assessments such as Kleinman’s questions can be used during routine assessment as a screening tool, with dedicated longer-format Power–Threat–Meaning Framework (PTMF) or DSM-5 CFI interviews reserved for cases where culturally mediated factors may be especially salient, as identified by initial screening questions. A deeper cultural understanding in these cases in the form of PTMF or DSM-5 CFI may reduce diagnostic misinterpretation and strengthen the therapeutic alliance, a valuable prospect in groups traditionally associated with worse clinical outcomes, such as in migrant populations.^{Reference Anderson, Giacco, Bird, Bauer, Pfennig and Lasalvia4}

We particularly agree that accurate cultural formulation using the biopsychosocial–anthropological (BPSA) model would be valuable in the context of psychotherapy, where a patient’s cultural background will highly influence attitudes towards treatment.^{Reference Ziyachi and Castellani5} Formally using the PTMF or DSM-5 CFI as part of the formulation process will enable the clinician to build a better understanding of the patient’s schemas, expectations and assumptions to improve modality selection and dedicated psychotherapeutic approach. Critically, this will also identify patients for whom Western psychotherapeutic constructs are incongruent with worldview and may therefore be less beneficial than traditional healing practices or community-based support. Furthermore, many patients have mixed cultural identities; incorporating a cultural dimension into the formulation process also accommodates for this, where attitudes towards mental illness can be understood as a spectrum rather than binary distinctions between different cultural groups.

It is also interesting to consider that the biopsychosocial model is not specific to psychiatry, and that the same would apply to the BPSA model. For example, culture is a significant psychological factor in facial plastic surgery decisions^{Reference Tokgöz and Carro6} and may affect a patient’s identity goals,^{Reference Arian, Alroudan, Alkandari and Shuaib7} influencing their therapeutic relationship with the surgeon. We would therefore expect that the BPSA model could be standardised beyond the context of psychiatry alone.

In many cultural contexts mental illness is viewed as occurring beyond the individual, shared within a community. Alternative medical systems and cultural phenomena such as stigma and shame can direct patient expectations and attitudes towards services. While we agree that the BPSA model would be a valuable extension of the biopsychosocial model, its success depends on implementation in patients vulnerable to cultural misinterpretation, and consideration of how best to practically implement the model within psychiatry and wider healthcare. The challenge is therefore not in the integration of anthropology itself but in doing so in a way that enhances clinical reasoning and improves outcomes.