Introducing The Concept of Diagnosis Cultures

Chapter 1
Introducing the Concept of

Diagnostic Cultures
This chapter has two main purposes: first, I shall introduce the very idea of
diagnostic cultures, which will be analyzed throughout the book, and second, I shall
articulate the theoretical approach that will be used to analyze the phenomenon of
diagnostic cultures. This approach is cultural psychology.
Living in Diagnostic Cultures
In one way, it should be quite easy to pinpoint the phenomenon of diagnostic

cultures, because we (and when talking about “we”, I include everyone in the
imagined hemisphere we call the West, but also elsewhere on the planet) live
in and with these cultures in almost every arena of social life, whenever people
experience problems or act in ways that are considered deviant. Formal psychiatric
diagnoses are not as old as one might think. The first edition of the diagnostic
manual published by the American Psychiatric Association, called the DSM,1
appeared as late as 1952, and although diagnostic terms were of course used before
this time, it was only from the second half of the 20th century that psychiatric
diagnoses really spread from practices in clinics and hospitals to schools, welfare
organizations, and families. Today, most of us can use diagnostic terms such as
depression, anxiety, bipolar, ADHD, PTSD and OCD, and also semi-diagnoses
such as stress, when we talk about the problems that we or our children face in
everyday life. We read self-help books about how to manage various psychological
afflictions that can perhaps be diagnosed, and consume novels and television
series (e.g. The Sopranos) in which the heroes or villains suffer from diagnosable
Copyright © 2016. Taylor & Francis Group. All rights reserved.
mental disorders. When we open our newspapers, we are routinely confronted

with frightening statistics that tell us, for example, that the WHO expects that
depression will become the second leading cause of global disability by 2020; we
learn that up to one quarter of the population is mentally ill within any one year;
and we witness how pharmaceuticals against symptoms of depression, anxiety and
ADHD are prescribed to more and more people – children and adults alike. Even
in Denmark – allegedly the happiest nation in the world – more than eight per cent
of the population consumes antidepressants, and for some age cohorts (especially
older people), the number is dramatically higher.
1 The Diagnostic and Statistical Manual of Mental Disorders.
Brinkmann, S. (2016). Diagnostic cultures : A cultural approach to the pathologization of modern life. Taylor & Francis Group.
Created from aus-ebooks on 2022-11-04 04:56:06.
8 Diagnostic Cultures
In what I call diagnostic cultures, psychiatric diagnoses are used by health

professionals and lay people for many different purposes. Psychiatric terminology
has been democratized and has travelled from the clinics and medical textbooks
into popular culture (witness the example in Box 1.1).
Box 1.1 Mad or Normal? Psychiatric diagnoses as entertainment
In 2012 the national Danish Broadcasting Company aired the documentary

“Mad or Normal?”2 The idea was to challenge people’s biases about the
mentally ill by showing that they are in most respects “just like you and
me”. The show was run in an entertaining way, somewhat like a quiz, and
hosted by a famous Danish “TV doctor”: three experts (one psychiatrist,
one psychologist and one psychiatric nurse) were confronted with a
group of ten people they had not met before, and five of these people
had different psychiatric diagnoses (schizophrenia, eating disorder, OCD,
social phobia and bipolar depression). Through the episodes, the experts
were supposed to match the diagnoses with five of the participants. The
viewers could also participate by voting on the internet, trying to guess
which of the participants were mentally ill. In order to help the experts and
also the viewers in this guessing game, the participants had to go through
a number of trials that were supposed to provide clues as to who were ill
and who were well. For example, they had to perform stand-up comedy
in front of a live audience (the idea being that this would be difficult for
someone with social phobia), and do a farm animal clean up task (possibly
revealing the OCD sufferer). But in fact – and seemingly in line with the
programme’s intentions – the experts could not guess who were ill, or
which diagnoses belonged with whom. And the viewers were also quite
poor at the guessing game.
What does a show like this tell us about diagnostic cultures and our
complex attitudes to mental illness today? Initially, it can be observed
that a show like this would have been quite unthinkable (at least in
Denmark) just a few years ago. Psychiatric diagnoses were not publicly
visible and would not be the centre of attention in a popular entertainment
show on television. Superficially at least, this indicates that psychiatric

problems are no longer taboo to the same extent and that stigmatization
due to diagnoses has decreased. Furthermore, and in rather more subtle
ways, the show points to a number of paradoxes inherent in the logics of
the diagnostic cultures of the 21st century. For example, one powerful
discourse, which is also mobilized in the television show, claims that
2 The show was a Danish adaptation of the BBC programme How mad are you? (See
Progler, 2009, for a brief description and analysis from a medical science perspective.)
Information on the Danish version can be found at: http://www.dr.dk/sundhed/Sygdom/
Psykiatri/Psykiatri.htm.
Introducing the Concept of Diagnostic Cultures 9
psychiatric problems are illnesses “just like somatic illnesses”, as it is

often said. In principle, there are no differences between somatic and
psychiatric problems, and the two ought to be equal in the health care
systems of the welfare state.3 At the same time, the underlying logic of
the show seems to go against this discourse of “illness equality”. This
can be seen if one imagines a similar show with people suffering from
somatic illnesses. Would such a show be aired, with the participants
having to go through trials that would bring forth their symptoms? This
is very unlikely. Think of people with osteoporosis being forced to play
hockey, for example, or diabetes patients eating loads of sweets. For
some reason, it did not lead to public outcry (in fact quite the opposite)
that people with mental disorders engaged in activities that were meant
to disclose their illnesses. This reveals the contradictory understandings
of psychiatric problems that we have in our diagnostic cultures: on the
one hand, they are “just like somatic illnesses”, but, on the other, they are
clearly implicitly thought of as something else.
Related to this point, it was noteworthy that the people with diagnoses
in the programme were said to be “not ill” at the time when the show was
made. For ethical reasons it seems reasonable, of course, to only enrol
people who are not overly vulnerable, and as a form of protection against
the tests in the show, but, given this, it is hardly surprising that the experts
and viewers were unable to guess who were suffering from the various
mental disorders. Also in the book, which accompanied the television
show, we hear that Kirstine (diagnosed with OCD) “is now cured”, and
she refers to her remaining problems as “bad habits, which everybody
has” (Kyhn, 2012, p. 46). Again, to compare with somatic illness: if
someone had once suffered a fracture, or had once had a tumour, but had
since been cured, then no one would ever expect that people (not even
experts) could come up with accurate guesses regarding these matters. So,
although the programme meant to transmit the message that “they” are
“just like us”, it paradoxically came to implicitly conclude that “once a
psychiatric patient, always a psychiatric patient” – even if the symptoms
have disappeared. The premise of the show was that it should be possible to
guess the disorders even though the (former) patients were now symptom
free, so, contrary to its surely good intentions, the show came to reinforce
a discourse of chronicity concerning psychiatric problems. Again, we see
the contradictory logics operating in diagnostic cultures: on the one hand,
we define and identify mental disorders on the basis of symptoms (which
is something I shall return to a number of times in this book), but, on the
3 Recently, in Denmark, a ”diagnosis guarantee” has been established, which means

that patients have the right to obtain a diagnosis within one month of contacting the medical
system. At first this guarantee did not pertain to psychiatric diagnoses, but this has now
been changed, so that all kinds of health problems are put on an equal footing.
other, we hold the belief that such disorders may somehow persist even in
the absence of manifest symptoms.
A couple of years later, in 2014, the show was followed up with two new
episodes called “Mad or Normal? At the Job Interview” and, instead of mental
health experts, three business managers were confronted with disguised
psychiatric patients in a group of job applicants, and asked whom among
the participants they would be interested in offering a job. Interestingly, the
managers were very positive toward many of the people with diagnoses,
and the “winner” was in fact a psychiatric patient. This second series,
now thematizing psychiatric diagnoses and work life, demonstrates yet
another paradoxical aspect of our diagnostic cultures: On the one hand, it
is surely very positive that people who are diagnosed are considered “one
of us” (which was the name of the accompanying national campaign to
raise awareness about psychiatric disorders) to the extent that experts and
business leaders cannot recognize them in a group of people. This can be
seen as a demonstration that “they” are indeed “like us”. However, they are
still “they”, and paradoxically identified as excluded through the diagnostic
label. On the other hand, the argument or demonstration of just-like-us-ness
can quickly be turned on its head to become a demonstration that if they
are “just like us”, then why do they need special welfare benefits, pensions
and other societally sanctioned advantages? The accompanying book asks
the question directly: “If the three experts in the program are incapable of
guessing who among the ten participants suffer from which disorders, then
how on earth should the rest of us be capable of guessing it?” (Kyhn, 2012,
p. 9). It might be a good thing in an ethical sense that viewers discover
that psychiatric patients are nice people without dramatic problems, but the
downside is that it might at the same time become difficult for patients to
explain their sufferings and legitimize their need for help. This illustrates
a broader dilemma concerning psychiatric diagnoses that will surface in
various ways in this book: diagnoses may on the one hand be stigmatizing
and pathologizing (and thus something one might wish to avoid), but, on
the other hand, the labelling they provide can bring certain advantages in
the diagnostic cultures of welfare states, which explains why some people
actively seek to be diagnosed.
Box 1.1 is about psychiatric diagnoses as entertainment, or perhaps more accurately,

“edutainment” aired on a respected public service television channel in Denmark,
and it is meant to illustrate some of the ways in which diagnoses are conceived
in contemporary society. From this little example, we have seen that a number of
paradoxes are likely to emerge when dealing with psychiatric diagnoses today: (1)
Through diagnoses, psychiatric problems are addressed as medical problems – and
yet they are not just that; (2) Through diagnoses, psychiatric problems are equated
with manifest and sometimes transient symptoms – and yet diagnoses have a
tendency to reinforce chronicity; (3) Through diagnoses, psychiatric problems
appear as “nothing special”, because many of us could be diagnosed at any given

point in time – and yet normalizing the disorders may cause problems for people if
this means that their problems cannot be recognized as sufficiently serious. There
are indeed many paradoxes inherent in the logics of diagnostic cultures, which in
itself might add to the suffering felt by those who live in these cultures and are
diagnosed. Unsurprising, it is easier to explain one’s problem to oneself and others
if it can be physically observed like a fracture or a tumour.
Expanding Diagnostics
The term “diagnostic cultures” is meant to point to the spread of diagnostic

vocabulary and associated social practices to new areas of sociocultural life. But
it is also meant to designate more concretely the increasing number of people,
who are “living under the description” of a diagnosis (Martin, 2007). Today, we
witness a diagnostic expansion in (at least) two ways: In many countries, more and
more people receive a psychiatric diagnosis, and new diagnoses are continuously
fabricated and suggested, some of which end up entering the official manuals (ICD
and DSM), while others stay on the fringes of medical practice. In 1952, when
DSM-I appeared, there were 106 diagnostic categories in a manual of 130 pages.
In 1994, with DSM-IV, the number of diagnoses had increased to 297 in a manual
of 886 pages (Williams, 2009). And now that DSM-54 has been published, we see
15 new diagnoses (including hoarding and cannabis withdrawal), and elimination
of a few others (most remarkably Asperger’s Syndrome). The number of official
diagnoses thus increased dramatically in the latter half of the 20th century, but
seems now to be slowing down.
In spite of the different changes, Rachel Cooper concludes in her recent book
on DSM-5: “The most striking thing about the DSM-5 is how very similar it is
to the DSM-IV” (Cooper, 2014, p. 60). This is particularly striking in light of
the huge efforts that were put in to discussing and reconstructing the diagnostic
system. Originally, the ambition while developing DSM-5 had been to instigate
a paradigm shift equivalent to that which occurred in the transition from DSM-
II to DSM-III in 1980. The transition in 1980 had implied a change from an
etiological approach to diagnosis, with the doctor employing a holistic approach

that took the patient’s entire biography into account, based in large parts on
psychoanalytic theory, to a purely symptom-based approach to diagnosis
in DSM-III. Horwitz has simply referred to this transition as one in which
etiological psychiatry was replaced by “diagnostic psychiatry” (Horwitz, 2002).
After DSM-III a diagnosis was (and is still) made by counting symptoms within
a given period of time (e.g. two weeks). The change to DSM-5 was thought to
imply a similar shift, only this time away from a categorical approach, where
4 Note the change to Arabic numerals, which is thought to facilitate the creation of
more editions of the manuals in the future, e.g. DSM-5.1, DSM-5.2 etc.
one either has or does not have a mental disorder based on the number and
severity of symptoms, to a dimensional approach, where everyone can be placed
somewhere on the continua. But the efforts to construct a dimensional system
failed, and instead the chapters of the manual were reorganized. The similarity
of the two editions of DSM – number IV and number 5 – means that many of
the criticisms that were raised in response to DSM-IV (e.g. by Kutchins & Kirk,
1997) still pertain to DSM-5, and ironically are now voiced by people such as
Allen Frances who were centrally placed when DSM-IV was created (Frances,
2013). (Frances was the chair of the DSM-IV task force.)
In addition to the rise in the number of people diagnosed, and also in the
number of diagnoses that it is possible to give, there is according to some studies a
third kind of rise, viz. in the number of people who ought to be given a psychiatric
diagnosis, but who are currently not diagnosed. This is the problem of under-
diagnosis, which co-exists with claims about over-diagnosis. Strictly speaking,
these two tendencies can logically occur simultaneously if it is the case that ill
people are not diagnosed and well people are diagnosed. The difference between
the number of people who are diagnosed, and the number of people who ought
to be diagnosed, is called the treatment gap, because a psychiatric diagnosis is
in many societal contexts the obligatory passage point to treatment. According
to authoritative estimates, the treatment gap for most mental disorders is more
than 50 per cent (and for some, such as substance abuse, considerably higher),
which means that more than half of those suffering from a mental disorder are not
treated (Kohn, Saxena, Levav & Saraceno, 2004). References to the treatment gap
can be used by patient organizations, researchers, professionals, and the medical
industry to support the view that “more needs to be done” in finding and treating
the mentally ill among us. The diagnoses are here central, because they define
what mental illness is and how it should be found.
A good example of the discourse of expanding diagnostics can be found on the
webpage of the World Health Organization,5 which states the following:
Lifetime prevalence rates for any kind of psychological disorder are higher
than previously thought, are increasing in recent cohorts and affect nearly
half the population.
Despite being common, mental illness is underdiagnosed by doctors. Less

than half of those who meet diagnostic criteria for psychological disorders
are identified by doctors.
Patients, too, appear reluctant to seek professional help. Only 2 in every 5
people experiencing a mood, anxiety or substance use disorder seeking
(sic) assistance in the year of the onset of the disorder.
This is indeed a very dramatic message: the prevalence rates for any psychological
disorder are higher than we thought and are rising – now affecting nearly half of us
5 http://www.who.int/mental_health/prevention/genderwomen/en/
around the world! The disorders are underdiagnosed (cf. the treatment gap), in part
because people do not seek help when they suffer. Seemingly, the prevalence rates
are taken at face value, and the WHO does not even consider that one reason why
people do not seek help can be because they do not feel they have a psychiatric
problem – even when their problem meets the diagnostic criteria for a mental
disorder. Needless to say, it can also be the case that people do not receive help,
because no help is available (or is too expensive where they live), but the point is
that there are likely to be many reasons for not being treated for what is allegedly
a mental disorder.
The expanding diagnostics are seen around the world, but this book is almost
exclusively about the so-called West, where half of the population is said to be
mentally disordered in their lifetime and approximately a quarter of the population
within any one year (Wittchen & Jacobi, 2005). In the West there are certain, quite
fixed, ideas about what counts as mental disorder, as specified in the diagnostic
manuals, and although the DSM (in particular) affects the local understandings
of mental problems all over the world (Watters, 2010), there are still curious
differences and exceptions. One such exception was reported in June 2014 in
Nigeria, when Mubarak Bala was sent for psychiatric treatment because of a case
of atheism. His disbelief in God was here interpreted as a mental disorder, likely
an effect of schizophrenia, and he was detained against his will in a psychiatric
ward. Fortunately, he has since been released, but is allegedly living in danger
because of his (dis-)beliefs that were pathologized by the local doctors.6 This
extreme example illustrates the variability in what counts as mental disorder and
how psychiatry and larger cultural and political issues are intertwined. This is
easy to see for Westerners when finding an extreme case in Nigeria, but it is much
harder to notice in our own diagnostic cultures, given the way that the current
conceptualizations of mental disorder are being naturalized through the diagnostic
categories. That is to say, it has become hard for us Westerners to think of mental
disorder outside what is made possible by the psychiatric categories. This means
that the psychiatric-diagnostic discourse is close to becoming hegemonic, and
even those who are aware of the negative effects of diagnosis – who argue,
to quote Rachel Cooper, that diagnosis “suggests that the source of a problem
should be located within an individual, and […] tends to remove an issue from
the political or ethical domain” (Cooper, 2014, p. 4) – often remain caught in a

diagnostic language when addressing the problems raised by diagnostics: does the
pathologization of sadness make us depressed, for example?
At this point I hope I have provided enough examples to indicate what I mean
in this book when addressing the diagnostic cultures of contemporary society. It is
important to use the term cultures in the plural, because there is not a monolithic,
agreed-upon understanding of mental disorder delivered by the diagnoses,
and there is no unitary way that the diagnostic language is used. Diagnostic
categories are used in numerous ways, by sufferers, parents, teachers, managers,
6 See http://iheu.org/mubarak-bala-is-free/.
clinicians, medical doctors, psychiatrists, psychologists, researchers, policy

makers, social workers etc., and, within these different groups, there is also much
heterogeneity concerning diagnostics: there are patient groups that fight for the
right to be diagnosed (recognized) and others that fight against being diagnosed
(pathologized). How can one determine what in one case is a proper recognition
of suffering through a diagnosis and what in another case represents illegitimate
pathologization of deviant or eccentric behaviours? This is not an easy task, and
not something this book can settle once and for all. Instead, the task will be to
unfold the societal situation through the concept of diagnostic cultures, charting
some of the ways in which diagnoses operate in people’s personal lives and on a
larger social scale.
Nikolas Rose has recently summed up the societal functions of diagnoses in
(what I call) our diagnostic cultures (adapted from Rose, 2013), illustrating the
huge variability in how diagnoses work:
1. A diagnosis is a condition of suitability of an individual for treatment –

without a diagnosis of pathology, there is generally no case for treating
the person.
2. In insurance based regimes, it is a condition of financial coverage of the
cost of treatment.
3. For those who are employed, it can be a condition of legitimate absence
from work.
4. For those who are unemployed, it may be a condition for access to
welfare benefits.
5. For hospitals and medical establishments it is a central feature of patient
records, which often shape the allocation of funding from those who
commission services for various conditions.
6. For lawyers, it can be a condition for involuntary detention and treatment.
7. In the school system, a diagnosis may be the basis of allocation to special
educational provision.
8. For epidemiologists, diagnostic categories are the very basis of their
estimates and predictions that are based on assessments of incidence
and prevalence.
9. For planners of services, those estimates and predictions are the essential
raw materials for their work.
10. For funders of research, especially charities focused on a particular disorder,
diagnoses may delineate a problem that is really worthy of investigation.
The list could have been considerably longer, so although psychiatric diagnoses
were created as the work tools of psychiatrists, we see that they today operate
in and between a large number of social practices, in addition to providing the
individual with an experience of getting an explanation for his or her problems.
Diagnoses affect how people feel and interpret themselves, they enter different
social arenas (in schools, at work and at home) and are used to regulate a huge
number of practices, and they have complex histories leading up to how they are
used today. So where can one find an analytic framework that enables one to study
the phenomenological, discursive, and historical aspects of a phenomenon such
as diagnoses? My answer in this book points to cultural psychology to which I
will now turn. Readers who are familiar with this theoretical paradigm may jump
directly to the next chapter, and others, who find the theoretical framework overly
abstract, may also read the more content rich chapters first before returning to the
theory unfolded in the rest of this first chapter.
Cultural Psychology
Cultural psychology has a long history, going back quite directly to the work of
Lev Vygotsky in Russia in the early 20th century (Vygotsky, 1978), and more
indirectly to different philosophical bases. Vygotsky drew inspiration from
many sources, but was placed in the tradition of Marxism, trying to address
the relationships between mind and world, individual and society, dialectically
rather than as separate entities that somehow interact. One can trace this line
of thought back in time to philosophers such as Hegel and Spinoza, and it
stands in contrast to Cartesian dualist philosophies, depicting subject and object
as discrete entities. This is not the place to unfold a full history of cultural
psychology; others have done this much more thoroughly, for example Jaan
Valsiner and Rene van der Veer (2000). In their book, they trace the notion of
the social mind, which was found not just in the work of Vygotsky, but also in
that of American pragmatists such as John Dewey and George Herbert Mead.
The dialectical approach offers the idea that the mind is social, and that the
social is also “minded”. In other words, as Valsiner puts it: “Human beings
are individually social and socially individual.” (Valsiner, 2014, p. 53). It is
simply not possible to delineate two different ontological realms, one of minds
of individuals, and another of culture or “the social”. Instead, persons – human
beings considered as creatures with minds and not simply as physiological
organisms – belong to culture, and culture belongs to persons (Valsiner, 2007,
p. 21). This means that psychology, sociology and anthropology are all needed
to create the discipline of cultural psychology, and other disciplines could and
should be added, in particular history, because cultural psychology sees every
mental/cultural process as existing and developing in historical time. There is
a focus on culture as a historical process rather than an entity or substance.
Culture is not a thing, and, for cultural psychologists, it has no agentive or causal
powers (Valsiner, 2014). Thus, culture does not do anything; culture does not
act and culture does not cause us to act either. Culture is not a variable that
can be isolated and measured. “How much of our active life is determined by
culture?” is a meaningless question from this perspective, because culture does
not determine anything, and it would not be possible to calculate its relative
importance (alongside biology, nature or genes, for example) anyway. It would
be more correct to say that everything in the human world is cultural – just
as everything in the human world is natural (mainly because it is natural for
humans to live as cultural beings).
From the point of view of cultural psychology, only persons (not culture) act
(Brinkmann, 2011b). Unlike other psychological approaches that approach mental
phenomena as aspects of a mind, or neuroscientific approaches that view them
as aspects of a brain, cultural psychologists argue that psychological predicates
pertain to persons only. They are neither “mindists” or “brainists” but “personists”
(Sprague, 1999). This also separates cultural psychologists from many sociologists
who operate with social structures or entities as having some sort of agentive
power. Only persons have this kind of power, but no human action would be
possible without culture. So, even though culture is not a variable, a force or an
agent, it is everywhere in human life and minds. Culture is a name for all those
mediators that persons use when performing actions, thinking thoughts or feeling
emotions. Language, for example, is a cultural tool that mediates the human
capacity for conceptual thought and enables complex forms of communication and
self-consciousness. Language is particularly important for cultural psychologists
because it is what enables human beings to create a distance to the here-and-now
contexts that they are in. The process of creating distance – and reflecting upon
the context, one’s preferences and desires to act – is called semiotic mediation by
cultural psychologists (Valsiner, 2007, p. 33). Sign mediators such as language
are not exactly the same as means. For means quite directly enable one to realize
one’s pre-formed intentions (means-ends reasoning), whereas mediators at once
constitute and transform the intentions that they carry. When we think abstract
thoughts, for example, it is not the case that we have pre-linguistic ideas that we
somehow translate into language that we can communicate to others. Rather, it is
the case that we use language to think the very thoughts that we have. Language
is, as Wittgenstein said, “the vehicle of thought” (Wittgenstein, 1953, § 329). In
this sense, language mediates the activity of thinking, and the categories we use in
thinking mediate the actions we may undertake. I cannot celebrate Christmas, for
example, without the category “Christmas”, but this does not mean that Christmas
is a purely linguistic or discursive event. Obviously, Christmas is a set of practices,
which involve semiotic and material tools, ranging from trees and presents to
carols and holidays and many other things that have evolved historically. To return
to the notion of agency: cultural psychologists will argue (the quite obvious point)
that persons celebrate Christmas. It is not the tree or the presents that celebrate
this event; rather, persons are the irreducible agents in cultural life (Harré, 1983).
However, it is equally obvious that persons could not celebrate Christmas, or even
have the intentions to do so, without a whole range of mediators, some of which
are semiotic while others are material, both of which are equally important in
constituting the practices of Christmas.
Now, the ambition in this book is not to study Christmas cultures. Other
cultural psychologists could do this, and it would be a fascinating topic. The
ambition is to study diagnostic cultures, and the complexities already introduced –
of persons and practices, semiosis7 and materialities, all in dialectical relationships

– necessitate a comprehensive and yet precise framework of cultural psychology.
The various schools and traditions within cultural psychology put emphasis on
slightly different aspects of minded-persons-in-practices, and I find that they are
all legitimate and fruitful for the project of this book. This is why I will turn to
briefly unfold three aspects of sociocultural life studied by cultural psychologists,
but first I shall say a little bit more about the concept of mind, which is just as
important as culture for cultural psychologists.
What is the Mind?
In the version of cultural psychology articulated here, the mind is conceived as

normative (Brinkmann, 2006; see also Brinkmann, 2011b, on which the following
is based). This has significant consequences for the analyses of what we think of as
mental disorders, as we shall see particularly in Chapter 7. That the mind is normative
means that the mind cannot be equated with purely receptive or experiential
consciousness, or what is sometimes referred to as qualia in contemporary
philosophy of mind; nor can it be equated with any substance or entity, not even the
material entity of the brain. Why is that? Because if the mind were identical with
some causally operating process or entity in the world or brain, we could have no
way of distinguishing psychological phenomena from physiological ones, and since
we are in fact able to make this distinction, it means that the mind cannot be purely
causal. An example from Harré (1983) may illustrate what this means: although
dread, anger, indigestion and exhaustion all have behavioural manifestations as well
as fairly distinctive experiential qualities (qualia), we have no trouble concluding
that only the two former phenomena should be included among psychological (or
mental) phenomena, whereas the latter two are physiological. Why so? Because,
argues Harré, dread and anger are psychological phenomena to the extent that they
fall within a normative moral order, where they can be evaluated according to local
norms of correctness and appropriateness. Dread and anger do not merely happen,
like physiological phenomena, but are done (by skilful human persons), and are
therefore subject to normative and indeed moral appraisal. One can feel and express
legitimate as well as illegitimate anger, whereas indigestion may be painful and

annoying, but it is meaningless to say that it can be legitimate or the opposite. Mental
phenomena – our ways of perceiving, acting, remembering and feeling – do not
simply happen, but can be done more or less well relative to cultural customs, norms
and conventions. In short, they are normative.
To study the mind is thus to study a set of skills and dispositions to act, feel
and think in particular ways, and we cannot determine whether someone has a
skill by examining the person’s brain, but only by studying the acting person in her
practical life activities. To have a mind is not to have some “thing” attached to the
7 Processes involving the use of signs.
brain or the body (for skills are not “things”); rather, for a creature to have a mind
“is for it to have a distinctive range of capacities of intellect and will, in particular
the conceptual capacities of a language-user which make self-awareness and self-
reflection possible” (Bennett & Hacker, 2003, p. 105). In other words, using the
concept of mind is to use “a generic term for our various abilities, dispositions
and their relationships” (Coulter, 1979, p. 13). It is not to talk about a place (e.g.
the “inner world”) or an object (e.g. the brain). Hilary Putnam has made a similar
point from the standpoint of pragmatism: “the mind is not a thing; talk of our
minds is to talk of world-involving capabilities that we have and capacities that
we engage in” (Putnam, 1999, pp. 169–170). As we shall see in this book, this
has consequences for how we should address mental disorders as one species of
mental phenomena of persons.
Cultural psychologists reject the widespread tendency in psychology and our
culture as a whole to reify the mind by treating it as an independent entity, which
“does” certain things (attends, remembers etc.). The mind does not do these things,
just as culture does not do anything. Only persons do such things, and it is exactly
their capacities, abilities, capabilities and dispositions to do these things that we
refer to with the term “mind”. Valsiner (2007, p. 125) refers to a related fallacy
as “entification”, which is the fallacy of treating psychological constructs (e.g.
personality, intelligence or mental disorders) as causal entities “in the mind” that
cause persons to do certain things. Again, it is better to follow the pragmatist John
Dewey and insist that psychological phenomena are adverbial (see Brinkmann,
2013a); they concern things done, which means that there are no psychological
entities as such (e.g. intelligence, anger, depression), but only persons and what
they do (and they may indeed act intelligently, angrily, depressed etc.). (See also
Billig, 1999, for a convincing defence of an adverbial approach to the emotions.)
Thus, cultural psychologists insist that it is fruitful to think of the mind as a
verb rather than a noun, as an activity or process rather than a static entity, and,
when we do so, we address the mind as a normative phenomenon: as a set of skills
and dispositions to act, think and feel. With this framework some old problems
dissolve and new ones arise. The Cartesian problem of how to find a place for the
mind in a physical universe is no longer pertinent, for this problem presupposed
that the mind was an (immaterial) substance that somehow had to be hooked up
with the material world. If the mind is not a substance, though, it is neither material
nor immaterial. Skills and dispositions are hardly approachable in these terms. (A
question such as: “Are the golfing skills of Tiger Woods material or immaterial?”
sounds mysterious to say the least, for skills cut across such strange divides.)
Instead, the question to ask is what enables the skills and dispositions to unfold
and come under control of persons. The answer given by cultural psychology –
at least in the version advocated here – is that mediators constitute and enable
the skills and dispositions of people. So, there is an inner conceptual connection
between persons, minds, culture and mediators.
Elsewhere I have suggested that four sets of mediators are particularly
important in this regard (Brinkmann, 2011b): brain, body, practices and
technologies. These are generic sets of mediators, and it may sound strange to
talk about the brain, for example, as a mediator of mental life, but what it means
is quite simple: the brain can be thought of as a tool that mediates human life
activities. Humans use their brains when performing the cultural tasks that make
up a life (Harré & Moghaddam, 2012), and when the brain does not function
adequately, say, if someone begins to suffer from dementia, then it is sometimes
possible to use auxiliary devices such as Post-it notes with names written on
them, if the person cannot recall the names of things simply by using the brain.
This illustrates how technology (in a broad sense, including Post-it notes) can
serve a psychological function. In the same way, our bodies and the social
practices in which we participate mediate the ways we perform the tasks of
psychological life. I will return to this later in the book (Chapter 7), when I seek
to develop a cultural psychological understanding of mental disorder, which
builds on the idea that “disorder” can have many different sources in brains,
bodies, practices and material culture, and which identifies the important roles
played by our conceptual designations (e.g. through diagnoses).
Three Aspects of Sociocultural Life
This whole complex of acting, embodied persons in a sociomaterial world (who

may experience problems that can be diagnosed) has been studied from different
perspectives by different cultural psychologists. It is unsurprising that scholars
have needed to purify certain perspectives and downplay others, given the
complexity at hand. At least three distinct approaches can be singled out, which
are all important to the analyses of the present book. They are depicted below in
Figure 1.1.
Positive
Positive
role
role
model
model
Dependable
Dependable
Dependable
Dependable
Dependable
Positive role model Dependable Dependable

Dependable
Dependable Dependable
Positive role model Positive role model
Figure 1.1 Three aspects of sociocultural life
In the middle we have what most cultural psychologists agree on studying:

acting persons involved in social practice. We study not brains or information
processing apparatuses, but living, suffering, acting, feeling, thinking persons.
They – or we – can, however, only act in social practices. Celebrating Christmas
is only celebrating Christmas because of the social practices of this event and their
histories. Absent the historically developed practices of Christmas, and dancing
around the tree would be nothing but meaningless twists and jerks. Social practices,
however, are not static, but are constantly and creatively renewed and restructured.
Around the centre, we have three schools, or traditions, of cultural psychology,
which share many premises, but which have slightly different emphases and
approach acting persons from different perspectives.
We have the school represented by Richard Shweder (1990), who argues
that cultural psychology studies what he calls “intentional worlds”, which
are sociocultural environments that are constituted by the representations and
interpretations that human beings direct at it. Intentional worlds can usefully
be studied using phenomenological approaches; that is, approaches that take an
interest in the life world of human beings, how they experience and act in the
world prior to formulating explicit theories (e.g. scientific theories) about it. In
relation to diagnostic cultures, the phenomenological aspects concern how people
experience the process of being diagnosed and how diagnoses appear in their lived
experience.
Next, we have the school represented by Michael Cole (2003), whose cultural
psychology is a kind of activity theory or cultural historical theory. Coming from
a Marxist perspective, the key idea here is that human activity is mediated by
different material artefacts. Our relationship to the social and material world
is mediated by everything from shovels to computers. In relation to diagnostic
cultures, it is the case that diagnoses themselves can be conceived of as epistemic
objects (see the following chapter) that gain a kind of objective status when they
come to function in the world, and the object oriented aspects obviously also come
in when we look at how these diagnostic cultures are co-constituted by numerous
things and technologies, ranging from standardized tests and databases, to pills
and clinics. There is an entire material world that mediates the emergence of
diagnostic cultures – or, one could say that such cultures are partly “assembled”
by a range of material mediators (Latour, 2005).

Finally, we have the school represented by Jaan Valsiner (2014), which does
not deny the importance of intentional worlds or artefact-mediation, but whose
version of cultural psychology focuses our analytic attention on semiotic mediation
specifically. Valsiner’s cultural psychology is a version of semiotic psychology,
which means that it studies how human beings use signs, symbols, language etc.
as mediators in and of their lives together. The concept of culture here refers to the
semiotic mediation that is part of the system of organized psychological functions.
From this perspective, persons necessarily belong to culture – yet, culture
necessarily belongs to persons. In relation to diagnostic cultures, it is quite evident
that psychiatric diagnoses have a significant role to play as semiotic mediators
that are put to use by individuals and collectives to regulate a large number of
processes in modern society.
The three aspects focus on different approaches to cultural psychology, but
the view in this book is that they do not exclude each other; rather they provide
a more complete picture if put together. Contemporary diagnostic cultures have
an experienced aspect, since they are populated by living, sensing human beings
who often understand their problems in light of the diagnostic categories they
are offered by medical and psychological authorities. They also have an object
aspect with the many material mediators that play a role, and they certainly
have a semiotic aspect, which, in other traditions, is studied as discourses (Gee,
2005) or social representations (Schmitz, Filippone & Edelman, 2003). Each
is an aspect of a cultural whole, and each aspect is influenced by the others in
ways that cannot be predicted until one looks closely at the empirical world.
Diagnoses have a cultural history (as objects) and affect the ways in which people
experience their lives (phenomenology) and the ways they talk reflectively about
their problems (semiosis). As we shall see in Chapter 3, these are all aspects of
social practices, which represent the core of cultural life: acting persons in social
practices.
All aspects, as I see them, are infused with normativity, as I argued above,
and what is interesting in relation to psychiatric diagnoses and mental disorders
is that normativity becomes particularly problematic. Do persons really do OCD,
depression, ADHD etc. relative to cultural norms, or do these afflictions happen
to them? One significant conclusion of the present book (shared, for example,
with Martin, 2007) is that people in fact do their disorders through diagnoses,
although rarely in a fully explicit and willed manner. People do ADHD, but they
also have it, and might even come to think of themselves as being ADHD. These
three dimensions (which will be unpacked more thoroughly in the following
chapter) correspond in some ways to the aspects studied by cultural psychologists:
the phenomenological aspect is primarily about how people experience their lives
as suffering from a disorder. Thus, a phenomenological approach is useful when
one is interested in the self-identity of the diagnosed. The object aspect is about
what people say (using a diagnostic category) they have, when they have a mental
disorder. The diagnosis itself can here be studied as an object in the world with
a biography (Daston & Galison, 2007). Finally, people also perform or do their
disorders through the diagnoses, which points to a discursive or semiotic aspect
that stresses the performative nature of mental life. All aspects of sociocultural
life are affected by today’s diagnostic cultures – or so I hope to demonstrate and
discuss in the following pages.
Critiques of Psychiatry
Before moving on to the next chapter, I shall here return to the discussion of
psychiatry and diagnoses, by summarizing four of the most important critiques
that have been directed at psychiatric ideas, several of which will play important
roles in the remainder of this book (and are helpfully articulated by Busfield,
2011). By referring to these critiques, I hope to show that the discussion of
diagnoses plays a role in all of them, albeit in different ways.
(1) The first states that psychiatry is inhumane and ineffective, which is
a classic critique that was articulated, for example, by Erving Goffman (1961)
in a famous study of life in a psychiatric hospital. After the emergence of anti-
psychiatric movements in the 1960s and 1970s (represented by Ronald Laing,
Thomas Szasz and Goffman himself), much has changed in psychiatry, but the
classic critique has nonetheless been rearticulated in recent years with a focus on
the dangers of psychopharmacology and the use of force in psychiatric hospitals.
Well-known international critical voices are represented by Robert Whitaker
(2010) and David Healy (2012), who have argued that the so-called iatrogenic
effects (the disease producing effects) of long-term use of psychiatric drugs are
so massive that they often outweigh the possible benefits of using the drugs. This
conclusion is currently hotly debated, which testifies to the enduring relevance of
this kind of critique. I return to this point below, most thoroughly in Chapter 6,
where I present some interpretations of the current epidemics of mental disorders,
some of which might be related to the harmful effects of drugs. Since diagnoses
represent the gateway to treatment, they are at least indirectly struck by this first
line of criticism.
(2) The second major critique states that psychiatry’s categorical model of
psychopathology is faulty. Unlike Freud’s dimensional approach to mental disorder,
according to which everyone is to be found somewhere on the psychopathological
dimensions and axes (which means that we all, in a way, have a grain of each
of the mental disorders), current diagnostic practices are built upon the idea of
disease specificity, which implies that the mental disorders can in principle be
clearly delineated from each other, so that one either has them or does not have
them. As recounted above, when DSM-5 was developed, some commentators
hoped that it would change into a dimensional model, but it ended up building
on the same categorical approach as previous editions of the manual (Cooper,
2014). After Freud, it was especially Hans Eysenck who became famous for a
dimensional personality theory (according to which an individual personality can
be understood through the dimensions neuroticism, psychoticism and introversion/

extroversion), and who criticized psychiatry’s conception of disorder for its lack
of dimensionality. In the next chapter, I return to the notion of disease specificity
and its relationship to diagnoses.
(3) A third group of researchers, most of them belonging to the anti-
psychiatric movement, have radicalized the critique of the categorical model of
psychopathology and argued that it is misguided in the first place to even have
a concept of mental illness. Thomas Szasz is the best known of these critics,
who from the 1960s attacked what he called “the myth of mental illness” (Szasz,
1961). His critique is grounded in an argument that the concept of illness rightly
belongs to somatic medicine, since it logically refers to lesions and dysfunctions
in organs and other forms of bodily tissue. Szasz argued that instead of talking of
mental illness, we should approach mental disorders as “problems in living”. If
not, we simply stigmatize human suffering and deviation as pathological, and thus
medicalize and pathologize life, something that was particularly evident in the
Soviet Union, for example, when political dissidents were treated as mentally ill.
Pathologization will be a key theme throughout the book.
Partly as a reaction to the anti-psychiatric critique, it has become common to
talk about mental disorder rather than illness, but, in principle, the challenge for
psychiatrists remains the same regardless of the terminology: that of identifying
what it is that is disordered or ill, if it is not just (as Szasz would argue) the
individual’s way of life as such. For if it is uniquely a person’s actions that are
perceived as problematic (either by the person or by people around him or her),
then it seems reasonable to address these as problems in living that we rightly
judge in moral or legal terms. Discourses of illness or disorder seem to presuppose
a more clearly defined physical object that can be damaged and which calls for
medical judgment and intervention.
In recent decades, many researchers in the biomedical sciences have pinned
their hopes on the possibility that neuroscience can identify mental disorders with
a damaged object, viz. the brain (or parts of it), but so far no valid biomarkers have
been found in psychiatry that would make possible a diagnostic process using a
brain scan (Singh & Rose, 2009). Singh and Rose demonstrate that the widespread
idea that it is possible to diagnose psychiatric disorders through genetic screening
or brain scanning is wrong, and the hunt for biomarkers, which goes on in many
corners of the biomedical sciences, represents a remarkable shift in psychiatry
away from concentrating on identifying the causes of suffering (in ontogenesis or
social life) and to charting the physical correlates of experienced suffering. (See
also Rose & Abi-Rached, 2013, who provide a thorough discussion of the role of
the neurosciences in this regard.) There is much that indicates that the hunt for
simple, determining biomarkers is futile, since both the neurological and genetic
backgrounds to mental disorders are at once much more complex, heterogeneous
and particularistic than previously assumed. Singh and Rose conclude that
information from biomarkers alone is insufficient to explain most of the variance
in observed behaviors (Singh & Rose, 2009, p. 205).
The most thoroughly worked-out attempt in recent years to conceptualize the

“psychiatric object”, which may be ill or disordered, is that of Jerome Wakefield
(1992). His theory of mental illness is called the “harmful dysfunction” theory,
since it has these two components. In order for us to talk about mental illness,
Wakefield states, there should first be something that is harmful. A person can only
be said to be mentally ill, if that person experiences suffering or distress to some
extent. Wakefield explains how this first component is a value component, since
he believes that social norms and values determine the extent to which something
counts as suffering or distress. How much one should suffer in order for the
suffering to be pathological varies across epochs and cultures. Besides this value
component, there is also a purely factual component stemming from a dysfunction,
he claims. One is not mentally ill, just because one suffers, since suffering can be
caused by all kinds of problems and life situations. Only if the suffering is related
to a dysfunction in the person’s mental processes can the person rightly be said to
be mentally ill (or disordered).
Wakefield here mobilizes arguments from evolutionary psychology, where
researchers invoke the existence of genetically based “mental modules” to account
for mental functioning. Mental modules are said to be innate psychobiological
mechanisms analogous to physiological mechanisms in bodily organs. Just as a
heart can be dysfunctional, when something is wrong with it that makes it unable
to operate adequately as a blood pump, so a mental module can be dysfunctional
if it, say, causes a person to feel constant fear without any frightening object
being present. It is not pathological to feel fear if one is a soldier who is about
to attack the enemy, but if a similar kind of fear is felt in everyday situations that
are objectively safe and if the discomfort is caused by defective mental modules,
then we are entitled (says Wakefield) to talk about mental illness. The object that
may “break” and become dysfunctional (and thus produce mental illness) is thus
a mental module. In short, for Wakefield, a mental dysfunction is a failure of the
capacity of a mental mechanism to perform a function for which it was biologically
designed. I return to this theory in Chapter 7.
(4) This takes us directly to the fourth influential critique of psychiatry, which
is also in focus in the present book: that diagnoses pathologize. A consequence
of Wakefield’s two-component theory is that quite a few of psychiatry’s existing
diagnoses must be said to be pathologizing by implicitly breaking down the
distinction between life problems and psychopathology. Together with Allan
Horwitz, a medical sociologist, Wakefield has thus argued that the diagnostic
criteria for depression (Horwitz & Wakefield, 2007) and anxiety (Horwitz
& Wakefield, 2012) are overinclusive and do not make possible a necessary
distinction between common sadness and clinical depression, or between
normal fear and pathological anxiety. The main reason is that the component
of dysfunction has not been developed in psychiatric diagnostics. A diagnosis
is formulated by psychiatrists by examining the symptoms, and counting them
using checklists, and it is therefore much more difficult to assess whether the
symptoms are caused by an underlying mental dysfunction or rather by a given
life situation. Significant sadness, Wakefield and Horwitz maintain, should only
be diagnosed as depression if there is a dysfunction involved (and not just if the
person has been divorced or has suffered a loss, for example), but the existing
diagnostic category does not capture this difference adequately.
Wakefield’s theory of mental disorder as harmful dysfunction thus holds
significant critical potential, yet without being anti-psychiatric or rejecting the
concept of mental illness as such. It can serve to warn researchers and practitioners
in the psychiatric fields of illegitimate pathologizations of ordinary (harmful)
experiences and conditions, which are not dysfunctional (and therefore not
expressions of mental disorders). The main problem related to pathologization
is that unpleasant experiences and conditions may be related to various social
problems such as marginalization, poverty and social injustice, which run the risk
of being interpreted as individual psychopathology when looked upon through the
diagnostic lens – and when the authoritative understanding of some experience
or problem employs the psychiatric interpretation (and approaches something as,
say, depression), it is of course natural to act as if it is a psychiatric problem (and
treat it with anti-depressants, for instance). To repeat a basic point: the risk is
that pathologizing something leads to an individualization of social problems and
narrows down our ways of understanding and treating the problems that people
have (Brinkmann, 2014a).
However, there are also certain problems inherent in Wakefield’s theory, and it
has often been criticized (e.g. Bolton, 2008). Perhaps its most significant problem
is its lack of specification concerning what mental modules are. The theory rests
on the premise that there are such mental modules, developed in the course of
natural history to solve specific problems in humanity’s evolutionary childhood,
and that these modules are innate and relatively independent of sociocultural
contexts, but critics of Wakefield here (rightly, in my view) object that this
represents an outdated view of the nature-nurture relationship (in this case, the
relationship between mental modules and social practices), which presents them
as different and perhaps contradictory forces. Many contemporary researchers in
biology (e.g. Sterelny, 2012) and anthropology (e.g. Ingold, 2011) now reject the
idea that we can separate what is psychobiologically innate from what is acquired
socioculturally.
Human psychology, including the sufferings of human beings, is most likely
always biological and sociocultural in a way that makes it impossible to draw a
firm distinction between these as separate components. In the words of Lock and
Nguyen: “culture, history, politics, and biology (environmental and individual)
are inextricably entangled and subject to never-ending transformations […]
biological and social life is mutually constitutive” (Lock & Nguyen, 2010,
p. 1). This leads these authors to an intriguing concept of “local biologies”,
that Lock has worked on for several years (Lock, 2001). Such recent ideas of
entanglements of the biological and the cultural suggest that the very idea of
innate mental modules may be a myth, or at least too speculative to serve as the
basis for a theory of mental disorder. I shall not pursue this argument further
here (I return to it later in the book), but just conclude that even if Wakefield’s
theory has considerable problems regarding its positive definition of mental
disorder, it nonetheless offers a very significant critique of many existing
psychiatric diagnoses, since it highlights the widespread confusion of ordinary,
painful phenomena of life with mental disorders. I believe there is much to
learn from Wakefield’s critique of the pathologizing effects of some diagnoses
without having to accept his theory of mental disorder as such – and there is
likewise much to learn from scholars who break down the distinction between
the biological and the sociocultural in relation to mental disorders.
The four lines of criticism mentioned here – (1) that psychiatry is inhumane,
(2) that the categorical model is faulty, (3) that the very idea of mental illness
is misconstrued, and (4) that the diagnoses, or at least some of them, are
pathologizing – are important as a background to discussions of the notion of
mental disorder and of the relationship between diagnoses and disorders, which
will be central themes throughout this book.

Introducing The Concept of Diagnosis Cultures

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Introducing The Concept of Diagnosis Cultures

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Chapter 1

Introducing the Concept of

Living in Diagnostic Cultures

In one way, it should be quite easy to pinpoint the phenomenon of diagnostic

mental disorders. When we open our newspapers, we are routinely confronted

1 The Diagnostic and Statistical Manual of Mental Disorders.

In what I call diagnostic cultures, psychiatric diagnoses are used by health

Box 1.1 Mad or Normal? Psychiatric diagnoses as entertainment

In 2012 the national Danish Broadcasting Company aired the documentary

show on television. Superficially at least, this indicates that psychiatric

psychiatric problems are illnesses “just like somatic illnesses”, as it is

3 Recently, in Denmark, a ”diagnosis guarantee” has been established, which means

actively seek to be diagnosed.

Box 1.1 is about psychiatric diagnoses as entertainment, or perhaps more accurately,

appear as “nothing special”, because many of us could be diagnosed at any given

The term “diagnostic cultures” is meant to point to the spread of diagnostic

etiological approach to diagnosis, with the doctor employing a holistic approach

Despite being common, mental illness is underdiagnosed by doctors. Less

the political or ethical domain” (Cooper, 2014, p. 4) – often remain caught in a

clinicians, medical doctors, psychiatrists, psychologists, researchers, policy

1. A diagnosis is a condition of suitability of an individual for treatment –

of persons and practices, semiosis7 and materialities, all in dialectical relationships

What is the Mind?

In the version of cultural psychology articulated here, the mind is conceived as

legitimate as well as illegitimate anger, whereas indigestion may be painful and

7 Processes involving the use of signs.

Three Aspects of Sociocultural Life

This whole complex of acting, embodied persons in a sociomaterial world (who

Positive role model Dependable Dependable

Figure 1.1 Three aspects of sociocultural life

In the middle we have what most cultural psychologists agree on studying:

by a range of material mediators (Latour, 2005).

be understood through the dimensions neuroticism, psychoticism and introversion/

The most thoroughly worked-out attempt in recent years to conceptualize the

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