Normal or abnormal? 'Normative uncertainty' in psychiatric practice

The ‘multicultural clinical interaction’ presents itself as a dilemma for the mental healthpractitioner. Literature describes two problematic areas where this issues emerges - how to makean adequate distinction between religious rituals and the rituals that may be symptomatic of‘obsessive compulsive disorder’ (OCD), and how to differentiate ‘normative’ religious or spiritualbeliefs, behaviours, and experiences from ‘psychotic’ illnesses. When it comes to understandingservice user’s ‘idioms of distress’, beliefs about how culture influences behaviour can createconsiderable confusion and ‘normative uncertainty’ for mental health practitioners. In the absenceof clear diagnostic and assessment criteria on distinguishing between ‘culture’ and ‘psychopathology’,practitioners have had to rely on their own intuition and seek out possible ‘strategies’ or‘procedures’ from a contradictory and cross-disciplinary evidence base. Decontextualisation ofservice users’ experiences may result in the pathologisation of culturally ‘normative’ phenomenon,‘category fallacy’ errors, and poor health care experiences and outcomes for service users.This paper situates this dilemma within a wider debate that has concerned both thebiomedical and social sciences, namely, the unresolved question of ‘normality’ or ‘abnormality’.Indeed, issues that arise from dilemmas surrounding the question of ‘culture’ or ‘psychopathology’are intimately tied to wider cultural ideas about what is considered ‘normal’. Thedisciplines of psychiatry, psychology, and medical anthropology have struggled to establishworkable criteria against which to judge behaviour as ‘normal’, ‘abnormal’, or ‘pathological’.Three models for understanding mental ‘abnormality’ are evident in ‘transcultural psychiatry’(what is now commonly known as ‘cultural psychiatry’), and these models have correspondedclosely to the interpretive models used by anthropologists attempting to make sense of theapparent diversity of human societies . The three models of ‘absolutism’, ‘universalism’ and‘cultural relativism’ have not only important consequences for the nature and conduct ofresearch enquiry, but also have implications for how the dilemma of ‘culture’ or ‘psychopathology’is attended to in clinical practice.J Med Humanit