Case vignette

Understanding a patient's perspective on symptoms.

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Understanding a patient's perspective on symptoms.

A patient who recently immigrated from South America was referred to a mental health center for worsening depressive symptoms and experiences of hearing voices.

The therapist decided to use the cultural formulation interview in the intake to better understand how the patient experiences and conceptualizes their auditory symptoms.

As part of the intake, the therapist asked, “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe this to them?” The patient replied that the voices they hear are family members that have passed and that they are encouraging and supportive through difficulties.

They reported that they experience these voices as spiritual and as a connection to their family lineage. As a follow up the therapist used the prompt, “People often understand their problems in their own way, which may be similar to or different from how doctors describe the problem. How would you describe your problem?” The patient went on to describe their depressive symptoms, including worsening fatigue, periods of intense sadness and lack of motivation. They had started experiencing these symptoms after some arguments with family members and a rupture in their relationships.

As the patient did not express any concern about the voices they were hearing and focused on their depressive symptoms, the therapist focused the rest of the session on their depressive symptoms and their family history.

Things to consider.


The therapist did not pathologize the patient’s experience of hearing voices. As the patient experiences them as positive, feels supported by them and pointed to their depressive symptoms as the presenting issue, the therapist chose to focus on this during the session.


If the therapist had focused more on the voices and tried to change the patient’s viewpoint of their origin and meaning, the therapist would potentially risk a therapeutic alliance rupture.

Question to think about:

How would you feel if a patient presented a different conceptualization of their experiences than you would expect or were taught?