Bipolar Expeditions (22 page)

We can describe social practices in such a way that these kinds of gaps and slippages take social rather than psychic form. Discursive psychology, an approach to the analysis of language in its social context, conceptualizes mental traits and dispositions as accomplishments that we achieve through social interaction. The argument is that we can understand psychological phenomena as brought about through social, linguistic activity instead of through private, inner processes within the individual. Accordingly, discursive psychologists argue that psychology should be based on the study of this outward activity rather than on hypothetical, and essentially unobservable, inner states.
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The sociologist Avery Gordon has pointed to the important role of repressed, mysterious forces that have no obvious cause yet have great impact on social life. These forces could be seen not as inborn urges beyond or outside language but instead as a constitutive resource of language, the social facts we do not want to recognize pushing into awareness.
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This would mean that dark, repressed forces in human life need not be hidden only in the psyche: they may be hidden within public social processes including language. Concealment could take place socially, through social interdictions against bringing certain social practices, identities, or roles together in the same context. Even the emergence of a particular subjectivity may be shaped by “certain absences, certain other enunciations that cannot or must not be expressed.”
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We might call this kind of concealment social rather than psychic repression. We might expect the interdictions involved to draw on common forms of social bias, for example on discrimination by race, sex, or class.

The sociolinguist Don Kulick provides a telling analysis of “social repression” as it works to produce gendered subjectivities. Kulick argues that sexual subject positions are crucially structured by “enunciations that cannot or must not be expressed.”
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A person who is socially a “‘heterosexual woman' is supposed to say ‘no' [to male desire for sex]—this is part of what produces a
female sexual subject.
A person who is socially a ‘heterosexual man' is supposed to
not
say ‘no' [to female desire for sex]—this is what produces a
male sexual subject.”
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When a “gay man” approaches a “straight man” with a request for sex, the “straight man” is placed in a position he often feels to be intolerable. Having elicited the gay man's desire puts him in an impossible position. If he says “yes” he will be in the subject position of a gay man; if he says “no” he will be in the subject position of a woman. When a straight man feels degraded by being forced into the subject position of either a gay man or a woman, that is when violence often breaks out against the gay man. These various subjectivities—gay, straight, man, woman—are shaped by social rules that prevent particular behaviors from being brought together.
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The case Kulick analyzes is quite different from rounds, because saying “no” to the categories of the doctors (though the speaker may wish otherwise) is
not
part of a system of “nos” (as in the case of Kulick's analysis) that people actively use to produce the subjectivity they desire. On the contrary, saying “no” to a medical diagnosis is often taken by doctors to indicate that the speaker is “mentally ill.” Indeed studies in psychiatry explicitly regard “poor insight,” defined as disagreeing with the psychiatric diagnosis one is given, as diagnostic of mental illness.
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The set of possible medical meanings for a person living under the description of mental illness is limited in such a way that efforts to refuse and resist are redefined as illness. In Mr. Burton's rounds, his attempts to describe his intentions and motives were met with a diagnosis of mental illness. He presented himself as an upright young man, well mannered and well loved by his family, who had already had significant successes at school and in work. His exposure to PCP caused him to become paranoid and suicidal and to obtain a gun; he reacted to an overload of past and present stress by leaving college. He realized he was in trouble and called for help, whereupon, in the Riverside emergency room, he was terrified because he was completely alone and threatened with injections he mistrusted.
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In the psychiatric description, in contrast, depression and anxiety led to changes in his daily habits, his ability to study, and his ability to tolerate being away from home. Depression also played a part in his suicidal and paranoid thoughts and his purchase of guns. PCP was granted a possible role, but overall Mr. Burton displayed a pattern of depression followed by mania: on admission his tangential speech and grandiosity indicated he was in florid mania. Because of the psychiatrists' knowledge and authority, there is no question that their descriptions will become operative in the hospital. Mr. Burton in effect tried to say “no” to the subject position of a person with bipolar disorder, but once he was defined as bipolar by the doctors, his effort was taken as additional evidence of his irrationality.

There is an important element of “performativity” in Mr. Burton's rounds, as there is in the other rounds and in the small, mocking performances I described in
chapter 2
. In the words of the philosopher J. L. Austin, “performativity” means that “There is something which is
at the moment of uttering being done by the person uttering.”
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When a judge of the appropriate kind says the words, “I now pronounce you man and wife,” the uttering of the words brings about, performs, the state of marriage. For the couple, two new subject positions, a “husband” and a “wife,” come into being.
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Because the rounds physicians are by definition the ones with the knowledge and authority to diagnosis mental illness, their words—Mr. Burton has bipolar disorder—performatively bring about a new subject position for him: he becomes a person living under the description of bipolar disorder. The other form of subjectivity that often struggles (but fails) to emerge in rounds is the rational subject, one who has self-knowledge and agency and, most important, the ability to make sense of unfolding events. Paradoxically, from the point of view of the person being diagnosed, saying “no” to the categories of mental illness, though the speaker may wish otherwise, is often taken to mean, constitutively, that the speaker is “mentally ill” and hence not capable of being a proper “subject” at all.

Patients in rounds, in striving to articulate an oppositional stance to the medical categories, are expressing a positive desire for a number of things: some wish for a kind of subjectivity and agency that would allow them to refuse to be described in pathological psychiatric terms because their individual cases do not fit it (Mr. Burton, who declared he wasn't crazy); some wish for a kind of subjectivity that would empower them to refuse the legitimacy of psychological tests (Ms. Miller, who wouldn't spell “cloud” backward); others wish for a kind of subjectivity that would enable them to make their definitions of normal and functional stick (Ms. Vincent, who thought she was normal when she was speedy). These are probably only a few of the wishes and desires contained in these events, all of which go to make up one of the main forces pushing the waves in the ground-sea: the assertion of these patients' subjectivities in a place where the medical model provides little room for it.

In the final analysis, the medical taxonomy used by the doctors naturally enough wins out in the context of rounds, despite patients' occasional efforts to refuse diagnostic tests or to turn the diagnoses back on the doctors. The patients are literally on the hospital grounds, where doctors control almost completely the medications prescribed, the length of stay offered, and the reports filed. In addition, most patients want and need the doctors' goodwill and accumulated experience, which would, if the appropriate diagnosis could be matched with a tolerable treatment, ease their suffering. Many patients have been in this very hospital before and at least sometimes say that they benefited from their treatment. What I intend to illuminate through these brief glimpses into ongoing and complex processes are the many facets of the struggles patients engage in to demonstrate that the pathological irrationality entailed by their psychological condition does not encompass their personhood entirely. I also hope it is possible to see that the medical categories themselves have looseness in them, as any taxonomic system would—fuzzy borders and conditions that overlap with each other—which students can only learn to apply through analysis of cases. This system does not come with clear, unambiguous rules about how its terms should be applied.

I will end with one caveat. The father of performativity theory, J. L. Austin, clearly distinguished cases in which language was performative from cases in which it was not. Characteristically, the criteria of the difference lay in “the circumstances of the utterance”:
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“Thus we may say ‘coming from him, I took it as an order, not as a request.' “
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“From
him”
might mean the person could compel obedience or punish disobedience because of his social position or his willingness to use force. Clear cases of performativity in Austin's sense, which can be called “strong illocutionary force,” must be distinguished from others, which might only have “weak illocutionary force.”
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“I now pronounce you man and wife,” when said by a judge, a religious official, or the captain of a ship, constitutes the performative act of marriage, but pronounced by anyone else does not. “It's a girl!” pronounced by medical staff at a birth, and followed up by a written record, constitutes the performative act of “girling,” but, pronounced by the parents, the statement could not, unless the parents by chance had the authority to fill out a birth certificate.
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For acts with weak illocutionary force, the sense in which they are intended may be more aptly described as expressing a wish than as making a change in the world. This is the case for much of the backtalk by patients in rounds. No matter what anyone wishes, if the doctors say you are manic depressive and write that down in your chart, then that is what you are, in contexts in which medical authority operates. The territory over which medical authority operates is so vast that however powerful the wish to be classified otherwise, more often than not such a wish is without much effect on the world. But, nonetheless, expressing a wish expresses something about the person who says it: it manifests, however weakly, an aspect of a person's subjectivity: “The description of a wish is,
eo ipso,
the description of its fulfillment.” Keith Burton's kisses might, on this account, be understood as the expression of his wish that his attachment to his kin could become part of his medical description and be taken seriously as a real motive in the world. This could not be. Even so, expressing such a wish can be understood in Wittgenstein's words as a “description of its fulfillment.” One might hope that such expressions could be more effective in the world than wishes, but this would require medical knowledge to incorporate patients' social environments in a much more profound way. Short of that, we could hope that (within settings like clinical rounds) the efforts of patients like Mr. Burton to influence the medical understanding of their cases could come to be treated as a resource, motivated not by a desire to refuse a diagnosis but to enrich its meaning.

CHAPTER FIVE

 

Inside the Diagnosis

To dwell means to leave traces. In the interior, these are accentuated.

—Walter Benjamin,
The Arcades Project

W
hen I sat in on medical rounds, I knew I was in territory where medical authority would largely be able to form and control the terms of debate. Keith Burton and the others could try to refuse or divert this authority, and they could frequently apply medical terms in novel ways suited to their own purposes. But in the end there was no question who determined the diagnosis and the treatment. In contrast, roaming around among manic depression support groups, I often fancied myself in a sort of ethnographic wilderness, far on the outskirts of medical authority. I thought of fieldwork among the “mentally ill” (even though the condition is no stranger in my personal life) as being in an “elsewhere” or among “others.” I imagined myself capturing the intricate sentiments of those cast outside the range of reason and “good sense,” documenting their words of wisdom about emotions, moods, or other psychological states that would rescue them from irrationality and throw the category of rationality into question. In fact, my fieldwork showed something I did not expect: when describing their mental states in support group meetings (outside the context of rounds), people most often stayed within the narrow confines of categories—such as “bipolar disorder” or “depression”—whose terms are set by medical conventions such as the DSM and held in place by their required role in insurance claims, among other things. To my surprise, I found that people in support groups used standard medical terms without further elaboration, frustrating my hope of finding a rich, individually and culturally nuanced language about interior states.

DSM Categories as “Text-Atoms”

Work on the DSM as we know it today began in 1974, after the American Psychiatric Association (APA) appointed Robert Spitzer head of a task force to develop “precisely defined, symptom-based disease entities” for psychiatric illnesses:
¹
“The ideal, if not the practice, of medicine demanded measurement systems in which symptoms were direct indicators of underlying disease entities, precise classification systems, and clear criteria of therapeutic effectiveness.”
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DSM-III, published in 1980, was a radical change from DSM-II, which was oriented toward dynamic (psychoanalytic) concepts. Psychiatrists who wished to ally with the norms of biomedicine now saw the contents of DSM-II as vague, opaque, imprecise, and unfalsifiable.
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In accord with the goal of precise classification, in addition to names of conditions, such as “bipolar disorder,” DSM-III and the current edition, DSM-IV, have numerical designations. For example, my own condition is designated by the code “296.7”; “296” is the code for most conditions under the DSMIV category “mood disorders,” including Bipolar 1 Disorder and Major Depressive Disorder. A fourth and fifth digit can be added to the code after the decimal to indicate the nature of the most recent episode (e.g., 296.4 would specify that the most recent episode was “manic” or “hypomanic”). A fifth digit indicates the severity of the most recent episode (e.g., 296.43 would specify that the manic episode was “severe without psychotic features”). If only one number is added, 7 in my case, it means that the nature and severity of the most recent episode are not being specified. The system may seem arcane, but it is also potent. Since mental health care providers and patients must list DSM-IV codes on bills and claim forms before insurance companies and state or federal programs will reimburse them or issue support payments, many people have become generally familiar with the language of the DSM-IV. Generally speaking, since only physicians and other mental health professionals need to know the DSM numeric codes, most people do not use this level of abstraction in describing their conditions in support groups.
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