Toward a cultural psychology of mental disorder: The case of attention deficit hyperactivity disorder

Introduction

Cultural psychology is today a significant approach in general psychology. It is not monolithic, but rather happily internally divided into different perspectives that put emphasis on different aspects of human mental life: intentional worlds (Shweder, 1990), artifact mediation (Cole, 1998), and semiotic mediation (Valsiner, 2007). It is also quite influential in educational psychology and organizational studies that focus on human life within historically developed social practices. It is curious to notice, however, how relatively little today’s cultural psychology has to say about mental disorder, which is otherwise a key theme in psychology as a whole. In many people’s eyes, it is probably even the case that psychology’s raison d’être lies its ability to help us understand and treat mental disorder. Most theorizing on mental disorder in psychology has historically been dominated by psychodynamic, cognitivist, and behaviorist schools, and more recently by the neurosciences. It is well known that Vygotsky (1929) took a significant interest in abnormal psychology in children, or “defectology” as it was then called, but browsing through today’s authoritative sources on cultural psychology, such as The Cambridge Handbook of Sociocultural Psychology (Valsiner & Rosa, 2007), leaves one with the impression that an interest in mental disorder and suffering, particularly in adults, is more or less nonexistent. This is probably an unfair verdict, and there are certainly interesting studies of mental disorder here and there by cultural psychologists, but they are not in any way defining the field, nor does a well-developed theoretical account of mental disorder exist in cultural psychology today.

This article tentatively begins to articulate a theoretical account of mental disorder from a cultural psychological perspective. It is argued that cultural psychology has the potentials to develop a comprehensive understanding of mental disorder that combines awareness of the brain and body with sociocultural norms and practices without reducing mental disorder to either of these. In that sense, it may steer a course between essentialist models of psychopathology on the one hand, and radical social constructionist ones on the other. Attention deficit hyperactivity disorder (ADHD) in adults is referred to as an illustrative example, but the theory presented here has more general ambitions. Following the convention in much of the clinical literature, I begin by introducing a case of a person who has been diagnosed with a mental disorder (ADHD), before venturing into a more theoretical landscape.

Tom’s story

In order to have a concrete case to use as a springboard for the ensuing discussions, I shall introduce Tom. I first met Tom in the summer of 2013, when I began as a participant observer in a support group for adults diagnosed with ADHD (as part of the research project Diagnostic Culture, which studies the impact of psychiatric diagnoses—depression and ADHD are singled out as key cases—on individuals and society). I still participate in the group, which meets for about three hours once every month. Tom is there almost every time, and I have also interviewed him in his home. I do this fieldwork in order to understand how adults diagnosed with ADHD use the diagnosis in their own lives. They are not simply given the diagnosis as passive recipients, but are using it actively for a number of purposes. The category ADHD operates as a powerful semiotic mediator in their lives that enables them to interpret their past in a new light and develop specific hopes and possible developmental pathways for the future, while excluding others (Brinkmann, 2014b). I am interested in the phenomenological aspects of being diagnosed—how do people experience this process?—and also in how the diagnosis is used discursively by those who come to “live under the description” of ADHD, to borrow Emily Martin’s terminology (Martin, 2007). Most of the people in the group (there are usually around 15 people present at a meeting) have sought out the diagnosis themselves, either because their children have been diagnosed (and they can mirror themselves in the children’s problems), or because they have been through some sort of crisis in their lives (e.g., a stress related breakdown) that prompted a more thorough examination by the doctor and later the psychiatrist, which eventually led to the ADHD diagnosis. This is quite unlike the situation for children diagnosed with ADHD, who are very rarely (if ever) the ones who initiate a diagnostic process.

Tom, a man living alone in his mid-forties, has also wanted the diagnosis himself. When he tells his life story in an interview with me, he talks about a history of unruly behaviors, concentration problems, and also petty crimes in his late teenage years. He was adopted as a small child after having spent the first month of his life at an orphanage, and he talks repeatedly about his quite hefty temper. But there was no ADHD diagnosis in his school years, and he was simply seen as one of the “naughty boys.” After the school years, he was able to hold a number of jobs, he still has good friends, and he also used to have a girlfriend that he lived with. He describes himself as “an ADHD person who is functioning well.” He seems quite determined in his choices and opinions. For example, when he discovered that there was a long waiting list before he could see the psychiatrist and obtain a diagnosis (paid by the state), he decided to pay for the psychiatric assessment out of his own pocket, and he was finally given the ADHD diagnosis about six months before I met him for the first time. He is still in a process of reading and learning about the diagnosis and trying to adjust his medicine to an optimal level. He grows his own marihuana, which he consumes occasionally (but does not sell to others), and psychiatrists would probably see this as “self-medication.” He is currently unemployed, but, interestingly, his last job was as a support person for young people with various problems, many of whom also have the ADHD diagnosis, so he now knows the diagnosis both as a professional and as a patient.

Tom’s story is in some ways typical (e.g., concerning his history and problems as a child), but in other ways it is (like all life stories) unique. When interviewing Tom in his apartment, eating cake and drinking coffee, I remember very clearly that I had the thought that this person is not mentally disordered. So why was he given the diagnosis? What does it tell us about our current “diagnostic cultures,” in which more and more conditions are seen through the diagnostic lens (Brinkmann, 2014a), that Tom received a psychiatric diagnosis? Two things about Tom’s situation are particularly noteworthy in this context, and I shall use these as background information in the following discussion about the concept of mental disorder and how to approach this in cultural psychological terms:

First, Tom is a very organized person. His apartment is perfectly clean and tidy, and he has neat to-do lists placed on the refrigerator. He has prepared carefully for the interview with me, for example, by reading from a book on adult ADHD authored by a well-known Danish psychiatrist and a psychologist, and he has written down a summary of its central messages that he wants to show me in order to convey what ADHD feels like for him. The capability of organizing his life and daily projects goes against the diagnostic criteria for ADHD, where having “trouble organizing tasks and activities” and “is often forgetful in daily activities” are central. Tom is aware of this himself, but explains it by saying that “it is in order to avoid the chaos” that he has a high level of organization. In other words, he compensates so well—by using calendars and to-do-lists, and perhaps also his marihuana—that many of the symptoms of disorganization in fact disappear. The crucial question then becomes: If the symptoms disappear, is the diagnosis then still warranted? Diagnostic psychiatry has since 1980 (with the introduction of DSM-III) been based on an assessment of symptoms (rather than, say, an understanding of the etiology and underlying psychodynamics of the person), so, strictly speaking, it means that a disorder is only there if and when the symptoms are present (Horwitz, 2002). Paradoxically, this seems to imply that people’s compensatory actions will remove the pathology.

Second, Tom describes how his problems really emerged after an injury he suffered while he was in the armed forces. He was on a three-year contract and wanted to make a career in the military, but his leg was more or less crushed in a traffic accident, and he had to leave the military. Tom describes the forces as a very good place to work, and it seems evident that the symptoms of ADHD were not present in his life during this period. So, the next question (which is related to the former) becomes: Did Tom in fact have ADHD when he was in the military? Is it possible to have ADHD in an extremely organized context with clear hierarchies and task allocations? Do the social practices of the military provide an ecological niche, to use Hacking’s (1998) term, in which the cognitive problems otherwise associated with ADHD are eliminated?

The point of raising these questions is to say that how one answers them will depend on the theory of mental disorder that one (implicitly or explicitly) subscribes to. To simplify: essentialists on the one side will say that if one has ADHD, then one has ADHD all the time and everywhere, because the disorder is constituted by certain core neurocognitive deficits. Most social constructionists on the other side will say that ADHD is a socially constructed category that medicalizes and pathologizes problematic behaviors, and they thereby seek to deconstruct all pathological “essences” associated with the diagnosis. I shall explicate these divergent standpoints further in the following, before articulating a cultural psychological theory that is neither essentialist nor social constructionist (in a radical sense), but rather situational, relational, and mediational, and thus, I shall argue, more theoretically sound.

Essentialist and constructionist approaches to mental disorder

According to a number of leading analysts, the contemporary understandings of mental disorder in the West are heavily influenced by “biomedicalization” (Clarke & Shim, 2010). Despite the fact that no simple biomarkers have been found for any mental disorder in psychiatry (Singh & Rose, 2009), and even though diagnoses can only be formulated by evaluating and counting symptoms (and not through brain scans or blood tests), there is a huge interest among researchers in the neuroscience of mental disorder that trickles down to the public and its “folk psychiatry.” My argument is not that the brain is unimportant in relation to mental disorders (quite the contrary), but simply to point out that it is not possible to diagnose any mental disorder by looking at a person’s brain. The enormous interest in the neurosciences of mental disorder these years (depicted and analyzed in Rose & Abi-Rached, 2013) goes hand in hand with the success of Big Pharma, if not concerning the treatment of mental disorder (where the results are mixed to put it mildly, see e.g. Healy, 2012), but rather concerning the marketing and spread of pharmaceuticals against a number of conditions such as anxiety, depression, and ADHD. Today, the pharmaceutical industry is among the largest in the world with marketing budgets that are twice as large as the money they spend on research and development of new drugs (Frances, 2013).

Concerning ADHD specifically, the now standard account in psychiatry is one that approaches this condition as a neurocognitive deficit, resulting in inattention, impulsivity, and hyperactivity to varying degrees, which are seen as chronic symptoms that can be treated with stimulant medicine, but which can never be cured (Buitelaar, Kan, & Asherson, 2011). The neuroscientific approach easily (however not necessarily) invites researchers to think in essentialist terms and look for the core dysfunctional brain mechanism that is thought to be involved in ADHD. Scores of brain imaging studies are now published every year, which are interpreted in light of quite different theoretical paradigms. Some theories follow Russell Barkley who states that ADHD is at its core a disorder of behavioral inhibition (Barkley, 1997), while others are in agreement with Brown (2005), who argues that the deficit lies in the inner management system of attention. Maiese (2012) provides a very helpful comparative discussion of these essentialist models and their respective shortcomings. In either case, the ambition is to be able to pinpoint exactly what the alleged deficit is in essentialist terms. Perhaps ADHD is even a natural kind, some will say, that is, a specific illness entity that can be defined in terms of necessary and jointly sufficient properties, which ideally leads to a “strict in or out classification of all individuals” (Kincaid & Sullivan, 2014, p. 3). This, at least, seems to be the essentialists’ dream, which, if realized, would likely lead to more valid diagnoses linked directly to the brain rather than behavioral symptoms.

Among a number of problems related to essentialism, I shall merely mention two: First, as I have already pointed out, no “essences” (in the sense of simple biomarkers) have in fact been found in psychiatry as a whole, let alone in relation to ADHD. Essentialism rests on what the historian of medicine Rosenberg (2007, p. 13) has called disease specificity, which refers to the idea that diseases are specific entities that have a kind of independent existence beyond their unique manifestations in sick individuals. The idea of disease specificity is so ingrained in medical practices today that it is difficult to imagine that it was once different. But, according to Rosenberg’s studies, disease specificity is a cultural idea from the end of the 19th century that has enabled people since to imagine diseases as discrete conditions in an organism, which can be defined and separated relatively clearly from other diseases, and which are therefore identical with similar conditions in other organisms. To simplify: before the 19th century, there were sick people, and after there are actual diseases. Although the idea of disease specificity might apply to somatic medicine, where examples such as cancer or diabetes can serve as obvious illustrations, it seems quite problematic in psychiatry. As Frances (who was the architect behind DSM-IV) has recently pointed out: “Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause” (Frances, 2013, p. 19).

Second, and possibly even more detrimental to essentialism, is the sociological insight that disorders “are only intelligible due to the normative and social context in which they are found” as Bowden (2014, p. 422) has recently argued. Among philosophers of psychiatry today, there is widespread agreement that one cannot define anything as a disorder in the absence of social norms of normality and suffering (Horwitz & Wakefield, 2007). Even if we grant that what is today referred to as ADHD is a ubiquitous trait in human populations across time and place (as some evolutionary psychologists will say), we still need social norms in order to establish whether this trait represents a disorder or simply is “a way of being human.”

Such arguments have led some to the belief that all mental disorders are nothing more and nothing less than contingent social constructions. This, obviously, is the anti-thesis to essentialist accounts, which is often referred to as social constructionism. Social constructionist models of disorder dissolve essentialist definitions and claim that the whole range of problematic human behaviors represent disorders only because of social categorizations and not because of anything inherent in the people who suffer. Social constructionist models come in many versions that are more or less epistemologically and metaphysically radical, but they all seem to “encourage the view that social values and priorities are the sole historical determinants of medicine, music, and marriage,” as Church (2004, p. 393) writes in her account of social constructionist approaches to mental disorder. Some, like Gergen (1994), seemingly prefer to eliminate the “deficit discourse” of mental disorder entirely, incarnated in the diagnostic vocabulary, while others, such as the less radical Conrad (2006), argue that diagnosing people with the ADHD category is a species of medicalization that amounts to “social control.” The point is that abnormal behaviors, such as the deviance labeled as ADHD, “is not inherent to the individual, the act, or the situation, but [is] rather a process in which certain alleged ‘rule-breaking’ actions come to be defined as deviance” (p. 1). In other words, for a social constructionist, there are no mental disorders “out there”; they are all in the eyes of the pathologizing beholder.

If the essentialists tend to forget that social norms are needed to establish anything as a mental disorder, it can be argued that the social constructionists conversely tend to forget that suffering individuals very often look for “pathologizations” to explain their problems. This was also the case in Tom’s story recounted above. Tom has wanted the diagnosis himself, because he has lacked an explanation of his problems. With their eagerness to move beyond the individual to the social context, social constructionists not only fail to acknowledge that individuals may bring quite different problems into a context, but also that individuals may in fact be very positive toward the deficit discourses that social constructionists wish to eliminate for the sake of the diagnosed. In the words of Comstock, who has recently been charting the genealogy of the ADHD subject:

the conventional critical perspectives fail to account for how it is possible that so many would accept being controlled or ‘drugged’ within broad trends of ‘over-diagnosis’ except by simplifying (or denying) the role of the individual in subjectification through the worn out critical concepts ‘ideology’ and ‘social control’. (Comstock, 2011, p. 49).

A situational approach to mental disorders

The Danish medical sociologist Dorte Gannik (who sadly died much too early in 2012) devoted much of her career to developing a situational theory of illness, which is deeply congenial to cultural psychology (e.g., Gannik, 2005, 2009). Her work, which was based on studies of somatic illness, notably back problems, is little known outside Scandinavia, but her theory is noteworthy because of its simple elegance. While it is certainly relevant in relation to somatic medicine, it seems to be even more to the point concerning psychiatric problems.

For reasons similar to those I articulated above, Gannik rejected essentialist theories of illness and disease (although there is a conventional distinction between illness and disease, this is rendered problematic by her theory). She sees illness as something relational, “identical with a person’s interactive relationship with her surroundings,” and also as performative: “The theory abstains from approaching illness as something ‘in itself’ beyond those actions or reactions with which a person responds to everyday, bodily experiences” (Gannik, 2005, p. 332). She refers to the well-established fact that symptoms are pervasive in our lives, and most of us experience unpleasant sensations in our bodies every day. But symptoms are not diseases or disorders. She argues that we should talk about illness, disease, or disorder as something people “do” (perform, enact) in relation to physical and social environments. They exist only in and through the ways in which they are performed. This has also been argued by ethnographer and philosopher Annemarie Mol, for example, in her study of artherosclerosis (Mol, 2002). Mol says that we should not think of diseases as “constructed,” since this metaphor solely emphasizes human symbolic activities of social construction, thereby leaving out the body and the material world (p. 32). Instead we should use the metaphor of performance or talk about enactment. Objects such as disorders are enacted in practices, but this should not lead us to the view that they are simply done by discrete actors (who could just choose to do otherwise). Instead, the idea of enactment should suggest “that activities take place—but leaves the actors vague.” (p. 33). Enactments presuppose a whole range of mediators that make the doing possible. If we ask “Who does the doing?” (e.g., of ADHD), then the answer has to include not just the suffering person, for events “are made to happen by several people and lots of things. Words participate, too. Paperwork. Rooms, buildings. The insurance system” (p. 25). And much more. The complexity involved leads to a need for what Mol calls a “praxiographic appreciation of reality” (p. 53), which studies how things are brought into being in sociomaterial practices (I refer the reader to her book to get an idea of how to work methodologically with this perspective). Contra essentialism, this means that it becomes impossible to isolate the “essence” of a disorder in any one place (e.g., the brain), and, contra social constructionism, it means that many forces besides the purely human (e.g., symbolic or discursive) ones are involved.

Returning to Gannik we can say that her model likewise does not isolate illness/disorder to anything in the person as such (essentialism), nor to anything in the social system in itself (constructionism). Rather, illness and disorder are always found in a relation between a person (or organism) and life situations (constituted by sociomaterial practices). This relational perspective means that people’s problems are radically situated. They exist in their concretely situated manifestations only, and not in anything behind or beyond this. Thus, essentialism fails. But it also means that the problems are irreducibly real—as real as anything gets—and sometimes stubbornly real. Thus, social constructionism in its radical versions fails. We should maintain a moderate social constructionist outlook, because certain important factors related to mental disorder are socially constructed (e.g., some norms inherent in our social practices), but we should also acknowledge the importance of factors that cannot be said to be socially constructed. It is the relation between these factors that should be in focus. Gannik’s theory implies that treating people’s disorders relationally may involve changing the person (e.g., through cognitive techniques or drugs) or changing the sociomaterial practices (e.g., by inventing new cultural prosthetic devices or new discursive practices). The point is that someone’s problems are not to be located in a single place, but dispersed over multiple mediators, as I will call them in the final section of this article.

If we look at Tom’s story through this lens, we can see that his problems are not just socially constructed, and it seems unhelpful to claim that the ADHD diagnosis in this case is merely a species of social control (pace Conrad, 2006). There is felt suffering in his life, related to disruptive behaviors and a problematic temper, but, at the same time, this phenomenon seems to become ADHD only relative to certain sociomaterial practices and their norms, where the problem can be enacted as ADHD. A cultural psychology of mental disorders should ask what mediators are involved in a given case that makes this form of enactment possible (I provide a sketchy answer below).

A situational approach to Tom’s story also seems to imply that in certain contexts, such as the military, where the “symptoms” are not enacted, we should beware of concluding that he “has ADHD.” Perhaps, we need to conclude that Tom did not have ADHD in the military. From the situational perspective, one does not simply “have” ADHD (or any other disorder)—here, there and everywhere—but enacts it only when certain contextual conditions and mediators are present. And even in life contexts where the condition can be enacted (such as in schools), we see someone like Tom being able to remove or at least diminish his symptoms with the use of culturally available technologies such as to-do lists. As a cultural psychologist, one may hope that future research into ADHD and related diagnoses does not only aim to develop new drugs to target brain chemistry, but also the much more immediately significant (yet with much less prestige and money involved) everyday artifacts that may be used as cognitive “assistive technologies” (Gillespie, Best, & O’Neill, 2012).

Conclusions: The mediated mind and its disorders

If we follow Gannik and Mol and look for a framework between essentialism and radical constructionism, the question for a cultural psychologist becomes: What kinds of mediators are involved that makes the enactment of a given disorder possible? And the practice-oriented question becomes: How can these mediators be changed in order to help persons? Using the term “mediator” in this way obviously draws upon a tradition in cultural psychology of seeing the mind (and its disorders) as mediated. In previous general psychological publications (e.g., Brinkmann, 2011, 2012), I have developed this theory by arguing (a) that psychological phenomena (our ways of acting, feeling, perceiving, and thinking) are normative in the sense that they do not simply happen, but rather are done (performed, enacted) by persons relative to social norms inherent in social practices (see also Harré, 2002), (b) that the mind should be thought of not as an entity, but as a name for the skills and dispositions that enable persons to enact psychological phenomena, and (c) that a range of mediators are involved in the constitution of this enactment. Some of the mediators are literally tools, while others, such as the brain, can be thought of metaphorically as tools (Harré, 2012). The four major kinds of mediators are the brain, the body, social practices, and material artifacts. I shall briefly discuss how these may each be involved in the constitution of the ADHD phenomenon. Needless to say, I can only provide a sketch of the argument in this context.

Concerning the brain, it must be said that although no biomarkers for ADHD (or any other mental disorder) have been found that makes diagnosis possible, it is inconceivable for most researchers (including me) that the brain is not involved in constituting the ADHD phenomenon, for the simple reason that the central nervous system is active in relation to any psychological process imaginable. The brain is a tool that persons employ when they think, feel and act—or fail to do so in culturally sanctioned ways. A reductionist program in the neurosciences will study how thinking, feeling, and acting go on in the brain, but a cultural psychologist (who is open to the neurosciences) will rather insist that only persons (and not their brains) think, feel, and act (sometimes in ways that are labeled “ADHD”), although they definitely need their brains to do so. Large research programs now investigate the brains of people with the ADHD diagnosis (Buitelaar et al., 2011), and we will have to wait and see if something significant emerges (we know that the brain is plastic, which may mean that no common pattern—or essence—can be found in the brain across people diagnosed). In any case (and I consider this a quite trivial point), the brain is without doubt a mediator that is involved in constituting the ADHD phenomenon.

This also goes for the body. Not many researchers are concerned with the embodied nature of mental disorders, but Maiese (2012) is one exception in the case of ADHD. Based on a phenomenology of the body, she argues that ADHD represents a problematic bodily orientation through which a person interacts with and gives meaning to the world. She further argues that embodied affective framing mechanisms, which serve to help people understand what is important in different situations, are defective in people who suffer from ADHD. It is difficult to assess the degree to which this perspective applies to Tom, in particular because of the ways that he has organized himself in his home, which renders his everyday life predictable. But from meetings and conversations with many other adults diagnosed with ADHD, it is recognizable that some of them have trouble focusing on what for most other people is salient in a social situation (this sometimes leads to curious interpersonal misunderstandings).

Thirdly, and almost trivially from a social scientific perspective, is the way that ADHD is mediated by certain social norms as they are inscribed into social practices. Researchers have found, for example, that a child’s date of birth is a very powerful predictor of whether or not that child will get the ADHD diagnosis: Studies from the US show that a boy born in January has a 70% higher risk of being diagnosed than a boy born in December, because of the cutoff for being assigned to a grade (Frances, 2013, p. 141). What happens is that a child’s relatively immature behaviors are pathologized as ADHD within the social practices of today’s schools. With this, of course, I do not mean to imply that children really have ADHD because of their date of birth, but this finding certainly makes it evident that ADHD is co-constituted by norms about concentration and unobtrusiveness in modern society and specifically schools. In his account of the historical creation of ADHD, the historian Smith (2012) has even gone so far as to link the hyperactivity epidemic in the US with the “Sputnik panic” that emerged after the Russians succeeded in launching Sputnik in orbit around the earth, leading panicked American educators to reform US schools in order to be able to beat the Soviet Union, which allegedly had much more discipline compared to the reform pedagogy of John Dewey that otherwise had characterized the American school system. It is fascinating if global politics in this way leads to very local consequences for individuals who are diagnosed. For Tom, as I have tried to demonstrate, it is quite clear that his symptoms appear as problematic only outside the strongly organized context of the military, when he has had to lead an independent adult life, deciding every day what is to be done, when, and how. Modern life in the West has been described as involving a “tyranny of choice” (Schwartz, 2004), celebrating the autonomous, reflective decision-maker in numerous social practices, and this may create ecological niches in which people are prone to being diagnosed with ADHD if they do not live up to the norms of constant free choice.

Finally, the fourth kind of mediator is artifactual, involving all kinds of technologies. For some disorders, it is obvious that mediators of this kind are involved in the constitution of the problem: Dyslexia, for example, is only possible because of the existence of written language. Concerning ADHD, it is interesting that the diagnostic criteria include such things as “fidgets with or taps hands or squirms in seat” and “loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and mobile telephones).” In a world without seats (in school institutions), pencils, books, etc. (which are representatives of “learning technologies” as such), and without the relevant sociomaterial arrangements of education in which bodies are socialized to a certain type of behavior, it is difficult to imagine that ADHD could exist. Technologies may assist in the creation of disorders, but may of course also help alleviate symptoms, and I have already described how material technologies are used by Tom in attempts to regulate his life activities in various fruitful ways.

The point of listing these is to emphasize that the disorder cannot be isolated to any one of these sets of mediators, but must be seen as distributed between and across them. There is no essence anywhere that makes up ADHD in and of itself, but different mediators may be involved in different cases to constitute a problem as one of ADHD. Together, the mediators enable persons to enact their problems as ADHD: A working brain and body are needed, and so are social practices with norms and discursive categories, and also various artifacts (and I have not gone into details concerning the technologies of symptom check lists, pills, etc.). Talking about enacting ADHD—or living under the description of “ADHD” (Martin, 2007)—is not to say that people do that consciously. Behaviors that we designate as ADHD are not chosen, but they are also not completely mechanical. I agree with Martin (who talks about bipolar disorder) that being hyperactive “does not fit easily at either end of opposites like conscious/unconscious, habitual/novel; compelled/chosen; or innate/learned” (p. 83). We need a new language, a new scientific approach to “describe the terrain between these poles” (p. 83), since this is where most disorders are enacted. Moving into this terrain should be a task for cultural psychologists, if they want to study mental disorder, and they are particularly well equipped to do so because of their broad, holistic approach to mental life.

In conclusion, I can sum up my argument by returning to briefly to Tom. If my argument is valid, we should see Tom’s ADHD as mediated by his brain, body, social practices, and various technologies. Contra essentialism, it is not isolated to any one of these, and, contra constructionism, ADHD represents much more than a (pathologizing) discourse. Hopefully, a cultural psychological broadening of our approaches to mental disorder can also lead to innovative and humane ways of helping people with their problems. Sometimes, the best help is likely to be found by looking at a few of the mediators, but, in principle, I will claim that we should be able to address all of them. Cultural psychologists are particularly well equipped to study the mediators of social practices and technologies, but they should also be sensitive to the embodied nature of mental problems. It could be objected that Tom is a special case, and that other disorders manifest themselves much more systematically in people’s lives. This is probably correct, but I do not think that it invalidates the general argument that cultural psychologists should theorize mental disorders as enacted relational, situational problems, related to a mediated mind.