Metrics details. 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. 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.
A certain insight has made some headway within psychiatry. All this sounds plausible. Some account of culture and psychiatric diagnosis from epistemic, social, ethical or other norms must be given — or rather is already implied — in the diagnosis of mental disorder. However, before one can establish if a deviation is clinically significant, it is important to judge whether it counts as a deviation in the first place, hence the need for a suitable context as a basis for judgement.
This cannot be resolved, as indicated, solely by asking the patient, since what has potentially gone amiss, as judged provisionally, is his or her benchmark of what is normal or acceptable, and what is needed is an understanding of the context within which to further assess such a judgement. Clinicians do this on a daily basis; they do it implicitly through the process of diagnosis, particularly when there is an unquestioned assumption that patient and doctor share a cultural context.
There are, however, a number of conceptual and practical problems that undermine the usefulness of the cultural congruence construct. Elsewhere [ 3 ], pp. Instead, I proposed, we should seek an independent study of the cultural epistemology — presuppositions about the limits of experience and sources of knowledge — as a basis for assessing mental states.
Then it will be seen, to invoke an example I used in the paper, that while it might be normal for a Lakota Indian to experience the voice of a deceased ancestor, a white North American having a similar experience should evoke concern.
They asked:. If it really is a matter of cultural congruence, why not introduce the white North American to some Lakota, or to some other white North American voice-of-the-dead hearers? To what extent can these deviations be culture and psychiatric diagnosis across cultural contexts and in clinical practice? This paper attempts to address these questions to arrive at a conceptually sound and useful construct of cultural congruence.
Gaining some clarity on these issues requires an understanding of culture and psychiatric diagnosis concept of culture. The paper begins with a first-person account of two complementary ways in which culture is acquired: knowledge and participation. Section two builds on this account by drawing a corresponding distinction between symbolic and phenomenological conceptions of culture.
The latter is further developed through the articulation of the ways in which, through participation, socially acquired meanings and significances organise background intentionality. Section three employs this view of culture to address the four questions raised earlier.
The main argument is that a significant, since foundational, deviation from culture is not from a value or a belief as such but from culturally instilled experiential dispositions, specifically in what is salient to an individual in a particular context. A cogent concept of cultural congruence should be sensitive to this distinction. Section four demonstrates how the revised concept of cultural congruence can be applied, first, in the ideal context of an extended, ethnographic research setting and, second, in the more restrictive setting of the clinic.
Genuine cultural learning is a two-faceted process; it requires gaining knowledge of beliefs and symbols and participation in a social context, the latter essential for achieving shared perceptual attunement with the environment.
The following first-person account draws this distinction and serves to highlight the indispensability of direct engagement to cultural learning, an idea that will arise later in the article as a potentially, if partially, surmountable obstacle to the application of the concept of cultural congruence in the clinic.
In and I spent several months conducting field-work in the Dakhla oasis, one of six oases in the Western desert of Egypt. It is an innate capacity to do harm delivered unintentionally through a direct look when encountering abundance or beauty in situations that evoke genuine admiration and appreciation. In practical usage envy also implies a wish on behalf of the envier, motivated by bitterness, to see the other person stripped of these positive attributes.
On the other hand, the evil-eye may occur from a good, pious person, in the absence of any intention to cause harm.
It may affect animals, plants, material possessions and human beings. While it is generally understood that a person may not be able to control the evil-eye, there are certain protective prayers that should be invoked when abundance and beauty are encountered. In the first few weeks at the oasis I was able to thoroughly learn beliefs concerning envy and the evil-eye. Shortly after, I realised that applying this knowledge in context was not as straightforward as I had thought.
They had three healthy, well-fed cows, one of which was pregnant, in addition to several chickens, goats, and a couple of sheep. As we entered, they started the usual invocations when seeing abundance and the healer sprinkled over the pregnant cow some blessed-water he had previously prepared. I found myself caught in a double-bind. Not to praise what I saw is rude and may be construed as jealousy, yet to praise too much is to seem disingenuous or, even worse, an attempt to mask envy.
I felt palpable anxiety in trying to negotiate my response, consciously and delicately: praising sincerely yet in culture and psychiatric diagnosis measured way, looking but not staring, and sharing in the invocations they were repeating.
Knowledge of the cultural concepts of envy and the evil-eye in a relevant context had impacted on my responses. In time I found myself more comfortable at negotiating these situations. In fact, something else had occurred, a subtle yet significant shift in my engagement with the environment.
Before, I was concerned with applying the knowledge I had gained in order to understand why people around me were behaving in this way and to know how I should behave. Now, there was a natural sense culture and psychiatric diagnosis attunement with the same environment which earlier I had been at pains to interpret. And this was not a matter of speed of interpretation, of being more adept at applying knowledge to a situation in order to understand it.
This was now my environment of action, which did not emerge as an interpretive conundrum but as a medium imbued with significances and affordances. It was then that the experience of a pregnant cow was transformed from something which hitherto was only relevant in so far as thinking about it aided the interpretation of social situations, to something that was naturally significant, compelling me to act in certain ways.
At that point I considered myself to have achieved genuine cultural learning in that specific aspect of the sociocultural environment of this community. And this occurred through a two faceted process: knowledge of beliefs and symbols, and participation in a social context. The concept of culture is among the more complex academic concepts. It has multiple meanings and uses within and across different disciplines as well as the vernacular in which it is a widely used term.
Further, the concept has changed and developed through the decades in quite radical ways, and culture and psychiatric diagnosis of its earlier conceptions, now, to us, may appear surprisingly ethnocentric if not racist. By looking at how culture is acquired we have come to identify the ways in which shared meanings and significances condition subjectivity and influence behaviour.
This coheres with the central concern of this paper, which is to understand the relations between culture and subjectivity, when these relations can be said to be problematic, and whether or not it is possible to detect this.
As I have come to learn through my experience in Dakhla, cultural learning requires developing knowledge of symbols and beliefs such that one is able to share a cognitive understanding of social situations. It also requires participation in the ebb and flow of a social context in order to be attuned to the environment and be moved to feel and act in an immediate and natural way.
These two facets of cultural learning correspond to two views of culture which have developed over culture and psychiatric diagnosis course of the second half of the 20th century: the symbolic and the phenomenological. These views may be usefully thought to differ with regards to the answer to this question: In what ways does culture — understood as socially acquired meanings and significances — condition subjective experience?
Symbolic views emphasise the act of interpretation and meaning-giving, while phenomenological views, in addition, of course, to recognising the symbolic order, highlight more passive, prereflective modes of engagement with the world. In the remainder of culture and psychiatric diagnosis section, this distinction is further highlighted and the phenomenological view of culture is expanded upon through the concepts of intentionality and salience. The emerging account will provide a framework over which a more fruitful conceptualisation of congruence can be based.
Throughout the Enlightenment, culture stood in opposition to the body, and, more generally, to nature cf. This is evident, for instance, in the importance of grasping the phenomena of the evil-eye and envy.
The kind of context Geertz is after is the subtle understanding that enables one to interpret an eye twitch as a wink and not only an eye lid contraction.
Cultural symbols and signs invest the environment with meaning and through being shared permit intersubjective understanding and communication. Symbolic approaches to culture have been criticized as narrow and incomplete, and for eliminating the possibility of meaning and engagement that precede representation.
They privilege culture and mind over biology and body; culture begins where biology ends and the mind becomes a representational machine engaged in inferential relations with objects in the world, including its own body, and adopting the cultural framework to thematise and give meaning to what are culturally-neutral experiences.
Against this view, some anthropologists e. In what follows I will attempt to locate culture phenomenologically by exploring aspects of the concept of culture and psychiatric diagnosis and its relation to salience. In particular, I argue that far from being limited to reflective modes of engagement, the influence of culture can be seen in the organisation of background intentionality, specifically in the automatic attentive orientation by virtue of which certain aspects of the environment are imbued with more salience than others.
Intentionality is a basic characteristic of consciousness. Consciousness is always consciousness of something whether real or imagined. The memory of a friend, a hallucinated dragon, and a perceived car are all intentional experiences with the friend, dragon, and car being the respective intentional objects.
In Logical Investigations Husserl  [ 15 ] identified two inseparable aspects of intentional experiences: intentional matter and intentional quality. The intentional quality, on the other hand, specifies the type of experience; whether the object is remembered, judged, doubted, desired, denied, or feared cf.
The intentionality just outlined is active and thematic; it discloses objects in the world and takes up positions and judgements towards them.
It is founded upon more basic and passive forms of background intentionality. In Experience and Judgement  [ 18 ] Husserl writes:. The activity of perception, the perceptive orientation toward particular objects, their contemplation and explication, is already an active performance of the ego. As such, it presupposes that something is already pregiven to us, which we can turn toward in perception. Husserl then proceeds to provide a phenomenological explication of the passive process whereby aspects of the intentional background experience stand out and command the attention of the ego.
The second stage is the compliance of the ego with the initial tendency and the turning of the ego towards the object; a basic state of receptivity in which the cogito becomes active and may proceed towards reflective and thematic forms of intentionality.
How are certain particulars able to affect the ego, i. Husserl employs culture and psychiatric diagnosis example of a field of sensuous data as the simplest model to demonstrate the way in which the passive field of perception possesses prominences and particularities. The initial synthesis of a field of sensuous data occurs though elements that contrast with others and are raised to prominence. Homogeneity and heterogeneity both within and across different fields, e.
Husserl gives the example of a noise or a colour which on the basis of its intensity may exert a powerful or weak stimulus, and may initiate a turning-toward of the ego. But Husserl is not limiting his phenomenological explication to sensuous data. In summary, obtrusion upon the ego is a function of a discontinuity in a field of perception which arises on the basis of the insistence and intensity of stimuli whether of a sensuous or non-sensuous nature.
This raises the question: what other kinds of discontinuities are there? A helpful distinction can be found in neuropsychological research on salience and attention.