Jennifer Radden: “Rethinking disease in psychiatry: Disease models and the medical imaginary”


The first decades of the 21st century have seen increasing dissatisfaction with the diagnostic psychiatry of the American Psychiatric Association’s Diagnostic and Statistical Manuals (DSMs). The aim of the present discussion is to identify one source of these problems within the history of medicine, using melancholy and syphilis as examples. Coinciding with the 19th‐century beginnings of scientific psychiatry, advances that proved transformative and valuable for much of the rest of medicine arguably engendered, and served to entrench, mistaken, and misleading conceptions of psychiatric disorder. Powerful analogical reasoning based on what is assumed, projected, and expected (and thus occupying the realm of the medical imaginary), fostered inappropriate models for psychiatry. Dissatisfaction with DSM systems have given rise to alternative models, exemplified here in (i) network models of disorder calling for revision of ideas about causal explanation, and (ii) the critiques of categorical analyses associated with recently revised domain criteria for research. Such alternatives reflect welcome, if belated, revisions.

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Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application

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Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application. Philosophy, Ethics and Humanities in Medicine (Journal)

This article is part of the series: Towards a new psychiatry: Philosophical and ethical issues in classification, diagnosis and care


Cultural congruence is the idea that to the extent a belief or experience is culturally shared it is not to feature in a diagnostic judgement, irrespective of its resemblance to psychiatric pathology. This rests on the argument that since deviation from norms is central to diagnosis, and since what counts as deviation is relative to context, assessing the degree of fit between mental states and cultural norms is crucial. Various problems beset the cultural congruence construct including impoverished definitions of culture as religious, national or ethnic group and of congruence as validation by that group. This article attempts to address these shortcomings to arrive at a cogent construct.

The article distinguishes symbolic from phenomenological conceptions of culture, the latter expanded upon through two sources: Husserl’s phenomenological analysis of background intentionality and neuropsychological literature on salience. It is argued that culture is not limited to symbolic presuppositions and shapes subjects’ experiential dispositions. This conception is deployed to re-examine the meaning of (in)congruence. The main argument is that a significant, since foundational, deviation from culture is not from a value or belief but from culturally-instilled experiential dispositions, in what is salient to an individual in a particular context.

Applying the concept of cultural congruence must not be limited to assessing violations of the symbolic order and must consider alignment with or deviations from culturally-instilled experiential dispositions. By virtue of being foundational to a shared experience of the world, such dispositions are more accurate indicators of potential vulnerability. Notwithstanding problems of access and expertise, clinical practice should aim to accommodate this richer meaning of cultural congruence.