Models for Cross- Cultural Treatment of Depression: The ESFT Model

The goal of treatment is effective, understandable, and respectful care that is provided in a manner compatible with the cultural health beliefs, practices and preferred language.

Overall, patients who feel that their doctors listen to them and act in their best interest are more inclined to seek help from professional providers in times of need. (15)

The ESFT model described below will help you provide culturally sensitive care to your depressed patients.


The ESFT (Explanatory, Social Risk, Fears, Therapeutic Contracting) Model, developed by Joseph Betancourt, MD, Alexander Green, MD, and J. Emilio Carrillo, MD (36), consists of a series of questions that can uncover factors that affect a patient's adherence to treatment—such as motivations, fears about medications, or economic struggles.

The model uses the ESFT acronym to explore health beliefs, and is especially relevant to Depression care in recent immigrants.

Here is a brief description of the ESFT model:


The "explanatory model" element aims to reveal the patient's understanding and own experience of her medical condition.

Elicit the “Patient’s Explanatory Model” by asking:

What do you call your problem?
What do you think is causing it?
How does it affect your life?
How does your family feel about it?
What kind of treatment do you think will work?


The "social risk" aspect examines social and financial barriers to treatment adherence. 

Elicit a patient’s “Social Risk” by asking:

Does your insurance cover your medications?
Do you have access to a pharmacy?
Is it difficult to afford your medications or copayments?
How are your medications organized at home?
Do you have a pill box?

Fears and Concerns

The "fears and concerns" element looks at how a patient feels about taking medication, including concerns about side effects and dosage.

Examine the patient's concerns about treatment by asking:

How do you feel about taking the medication?
What have you heard about this medication?
What worries do you have about side effects?
Do you think the medication will interfere with your life?

Therapeutic Contracting

The "therapeutic contracting” aspect involves having the patient describe how he or she feels about the treatment plan and explain how he or she plans to take the medications or handle treatments

Check the patient's understanding of treatment, and elicit a contract from the patient about following treatment, by asking:

How do you plan to take the medications?
How do you feel about your treatment plan?
Can you repeat the (treatment) instructions back to me in your own words?