This chapter is a theoretical introduction to the treatment. This includes introduction to the model that guides treatment (the multiplex model), aspects of efficacy, and a review of studies supporting the approach.

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.

The DSM-5 Cultural Formulation Interview (CFI) and the resulting Handbook represent a unified and comprehensive attempt to provide guidance to clinicians (and researchers) on the integration of cultural assessment into overall psychiatric assessment, in a very methodological manner. The first notable piece of the puzzle is the global scope represented by its contributors. The institutions that are involved in the construction and field testing of the CFI include Columbia, Mayo Clinic, and Yale, but include a more global scope with contributions from Sweden, India, Peru, Spain, Netherlands, Canada, and Kenya. This is an appropriate and necessary collaborative approach when discussing cultural formulation. The current CFI was revised based on clinician and patient feedback during an international field trial from 14 sites in 6 different countries. The Handbook starts off introducing the idea of cultural formulation as the “single most practically useful contribution of cultural psychiatry and medical anthropology to clinical work in psychiatry” (xviii). The editors take great care to emphasize that the CFI, although developed for use in psychiatry, is truly a tool that can be used throughout general medicine. After all, cultural competence is not just limited to psychiatry but is also relevant in primary care and medicine in general. The CFI purports to be a best practices approach that can be systematically applied, but the editors caution that it not become so systematic that it becomes another piece of bureaucracy. An interesting point brought to light numerous times is the idea that clinicians should make an effort to learn about different cultures, but that this knowledge should not be used to stereotype individuals. The emphasis is on each individual’s unique interpretation of their culture(s), as a person may or may not ascribe to all aspects of the cultural group to which he/she belongs. The CFI should be used to rule out stereotypes, not feed into them. It is designed to be used even when the interviewer has no