Bipolar Expeditions (21 page)

Dr. Paulson:
Is anything not quite back?

Mr. Burton:
Well, my testicle is gone. But I feel great, great.

Dr. Paulson:
How is your energy?

Mr. Burton:
Great, I have like an extra little boost.

Dr. Paulson:
What's that like?

Mr. Burton:
I have more insight now. My mind goes faster than I can articulate it. That Riverside Hospital, I will never go back there again.

Dr. Paulson:
How do you feel about your self?

Mr. Burton:
Great! My whole self has had a boost. I have a job at the bank, I am going to invest in Phillip Morris, quit my job, and just watch my stock rise. I took the job to learn stocks, and I have learned them in a month. The head of the company says just invest in this stock, you will see. Like you were asking me if I remember the question you asked me, of course I remembered it, I just had to start back a little bit so I could make it clear.

Dr. Paulson:
So you are feeling pretty good?

Mr. Burton:
My future's so bright you gotta wear shades!

Dr. Paulson:
When else do you feel like this?

Mr. Burton:
When I come home from college to my family. I am so happy to see my mother, grandmother. [He gives them each a hug and a kiss.]

Dr. Paulson:
So last semester you lost interest in school?

Mr. Burton:
During Christmas break I didn't want to leave, I cried when I left. I should have known it was wrong to leave.

Dr. Paulson:
How were you sleeping?

Mr. Burton:
I was up early, and then later I would take a nap, then do homework. I would go to bed at 1 or 2 a.m.

Dr. Paulson:
Eating?

Mr. Burton:
I eat five meals a day.

Dr. Paulson:
Were you eating less or more than usual?

Mr. Burton:
I eat five meals a day, and of course I have to work out.

Dr. Paulson:
What about your thoughts about the gun? Did you ever have those thoughts before?

Mr. Burton:
I could have hurt myself a long time ago.

Dr. Paulson:
Did you have those thoughts before?

Mr. Burton:
No, it was the PCP. When I was younger, the worst part was not having control. It was pretty decent, except for not having my father living with me. My mother is chemically dependent. I am going to make sure she stays sober. I was the oldest, and when my mom was on a mission, that is what I call it when she goes after drugs, I was in charge of the kids, five or six of them, all these kids, feeding them, dressing them, getting them ready for school. The social services finally took all of us.

Dr. Paulson asked the mother and grandmother whether he seemed normal. They said, “He has all this stress on him. He had too much responsibility as a child. With all that he had on his head when he was younger, then he gets to college and it is overload.”

The interview came to a close, and Mr. Burton went around the room on his way out, making eye contact and shaking hands with each one of us, saying, “I have never seen so many doctors in one place in my life.”

Dr. Paulson began the discussion: “His speech was tangential and circumstantial. I think he would have gone on and on if I had not redirected.” Turning to the medical students, he asked, “Was he manic?”

A medical student:
He was overly dramatic, making himself known to us like that.

A second medical student:
Also making such a point of kissing his mother and grandmother.

A third medical student:
But he did have pressured speech.

Dr. Paulson:
Does he have manic syndrome?

Another medical student:
He seemed contrived. At this Dr. Jones interjected: He had a gun!

Dr. Paulson:
Let's see, are there any other students here … how about you?

An occupational health student:
I am in occupational health.

Dr. Paulson:
That counts! What do you see? Was he manic?

Occupational health student:
I know how he feels, he worries about grades and the rest of college, he is homesick, and with all that stress on him.

No one responded directly to this, so Dr. Paulson summarized, “I think he has bipolar disorder.”

In striking contrast to Mr. Anderson, Keith Burton did not end up in an unclear gray zone as a “normal variant,” a person whose behavior is typical of creative researchers, writers, and artists. In Keith's rounds, a set of life categories met a set of medical categories head on. Mr. Burton and his family wanted recognition of his difficult childhood and the responsibilities he had had to bear early on, his intelligence and success in college, his promising job, and his love for his family. His “craziness” consisted in his leaving college out of stress and homesickness. All these issues are contained to a greater or lesser extent in the resident's initial presentation, which makes the important point that the medical case history and the patient's narrative do share common ground.

The medical students saw him as overly dramatic, contriving to demonstrate his affection toward his relatives and his collegial status with respect to the doctors. They saw a
performance
of mania, which meant to them that it was not legitimate. As I argued in
chapter 2
, a deliberate dramatic quality could be considered part of mania, but in this context, because of Keith's control over his performance, the students wanted to define his condition as less than mania, as ill faith, not illness. The occupational health student identified with his life as a college student far from home and saw a normal reaction to stress. The doctors looked past these descriptions and saw him as under stress, to be sure, but more important, they saw him clearly experiencing by turns suicidal depression and florid mania. Medication, which could be life-saving, would be required at all costs. One might say the medical students reacted to him as a peer, competitively; the occupational health student reacted to him as a peer, sympathetically; and the doctors reacted to him as a patient, one who, despite his denials, must be protected from the consequences of his extreme states. The professionalization of the students required, however, that they learned to think of Mr. Burton as a patient with an illness, if doing so would help him.

From the rounds physicians' point of view, there was agreement that Keith Burton's case and Mr. Anderson's were distinctly different, the one a clear case of bipolar disorder and the other in a gray area. I would not want to debate the medical wisdom of this distinction, but I do want to turn to some less obvious aspects of Mr. Burton's case that complicate his clear diagnosis. As I mentioned earlier, there were forces hovering around this rounds that brought to my mind the image of a ground-sea. The term “repression” comes to mind here, not only in the sense that Freud used it, referring to something internal to the psyche, but also in a social sense. For example, Keith's testicle—which caused him great pain and had to be surgically removed—was dramatically absent in rounds. As Keith says, it was missing: not only from his body but also from the conversation. Since there surely would be other contexts, equally social, where the profound loss of a testicle could be discussed, why was it not discussed in rounds?

To suggest an answer, I turn to Mr. Burton's physical gestures of affection toward his mother and grandmother. The doctors and medical students did not see this behavior as evidence of Keith's ability to function socially. Still less did they see his direct eye contact, firm handshake, and respectful personal greeting as a part of polite behavior for persons of substance in African American culture. Rather, his behavior clearly made them uncomfortable and provided evidence that Keith was “overly dramatic.” These signs of affection were an intrusion into the effort to describe in medical terms what was wrong with Keith as an individual. But Keith broke out of the silence and away from the carefully controlled answers he was supposed to make to questions. A young black man who survived urban crime and drugs was now in college with a job headed for Wall Street, his future so bright he had to wear shades. The doctors, all white, might have been experiencing estrangement from his racial identity and his history, but they might also have been experiencing fear of his energy and power. He seemed to contain both too much life and too much death; his presence was disquieting.

Comparing Mr. Anderson and Mr. Burton, there were certainly legitimate medical reasons for giving Mr. Burton the unambiguous diagnosis of bipolar disorder: his posssession of guns not least among them. But the two cases shared elements, too. Both men struggled with mood as well as motivation. For both, motivation soared stratospherically and then faltered when self-doubt and depression struck. For both, mood cycles led to difficulty functioning well. (Recall that Mr. Anderson was relieved of his teaching duties.) Anticipating my discussion of the racialized dimensions of mania in
chapter 9
, the two men provide a hint of the strong connection between white identity and manic potency. Mr. Anderson can be seen as a successful (white) professor with foibles: his exuberance is overconfidence rather than mania. Mr. Burton can only be seen as a faltering (black) student: his exuberance can only be seen as manic in a disordered and “mentally ill” sense, not in an effective and powerful sense. The sharp lines we imagine separate the rational from the irrational produce a bind here: Mr. Anderson, being white, can be manic, potent, and rational at the same time; Mr. Burton, being black, can be manic, but in becoming manic he loses his potency and his “rationality.” The disallowed combination is to be manic, powerful, and black all at once. This bind is not a product of medical categories alone, but of medical categories working in combination with cultural categories that define race in relation to human capacity in historically specific ways. Finally, I can return to Mr. Burton's lost testicle. This literal wound—no doubt a topic of fear and horror to all the men in the room—was evidently unspeakable. There is no way of knowing for sure, but it is possible that the silence over this loss, the quintessence of an emasculating loss, came about because this wound lay too close to the other forms of emasculation going on in rounds at the same time.

Subjection and Rationality

Speak as he might, Keith remains subjected to medical authority. In contemporary critical theory, “subjection” is a technical term, one that can help us understand Keith's position. As part of the process of becoming a person of a certain kind, one becomes subordinated to power while simultaneously becoming a “subject.” For example, in philosopher Judith Butler's apt example, the announcement at a baby's birth, “It's a girl!” brings into being a subject who must, “to qualify and remain a viable subject,” embody the norms of femininity by “citing” or performing social norms that are required as part of becoming a woman. The convention in Euro-American societies that a person is one of two genders means there are only two choices—it's a boy or it's a girl: other possibilities must be excluded. This powerful process is circular: in order to become a person who can act in the world, one must be granted a legitimate social position (say, that of a girl); one's actions, to be socially legitimate, must work to fulfill the norms of that social position (femininity).
⁸
Paradoxically, as Michel Foucault made clear, our existence as subjects, as agents, depends on the existence of discourses outside us over which we have no choice.
⁹
Norms
appear
to come from
outside,
pressing down upon and subordinating the subject, but in fact one can only become a subject with the capacity to act in the world through those very norms. A social norm operates
inside
the person where it “assumes a psychic form that constitutes the subject's self identity.”
¹⁰
The circle closes if a subject's enactment of a norm consolidates the norm's apparently unchangeable reality. The circle opens if the subject feels at odds with the norm and takes action to subvert it. “Subjectivity” involves both whatever places a person occupies in the system of categories the culture provides, and whatever senses of identity the person has about those places.

The case that concerns me, the designation of rationality or irrationality, is not necessarily raised for every person the way gender is. One does not announce at birth, “It's a rational human being!” But when one's rationality does become an issue, through one's own experience or the observations of others, the disciplines of psychiatry and biomedicine offer a set of categories of health and illness in terms of which a person can be described, for example, as “manic depressive.” When this term was applied to me, I came to identify myself as “a manicdepressive person,” thus incorporating the tenets of this knowledge inside myself. But the circularity between norms and subject formation that Butler and Foucault stress leads to an uneasy conclusion in the case of mental illness. Since the category manic depression denotes an irrational condition, I appear to be trapped in a circular process that robs me of the ability to be a subject at all: once I occupy the subject position of the irrational, my actions will always be interpreted as irrational, no matter how much I protest.

To understand such a trap ethnographically, we need accounts of social life that refer not only to language but also to actions, ideas, dreams, institutions, roles, objects, exchanges, memories, expressions, gestures, and a multitude of other socially inflected practices.
¹¹
If we broaden and deepen the social contexts in which we explore subjectivity, we will discover gaps, slips, and sidelines similar to those Freud found in the psyche, famously calling their emanations “the psychopathology of everyday life.” Being able to see such gaps is important because they contain places where subjection fails to hold. Butler acknowledges that because a person's enactment of a norm such as femininity never completely instantiates the norm itself, institutions and authorities must make repeated efforts to shore up the norm and strengthen its hold. Just as the gender norms are, in Butler's phrase, “haunted by their own inefficacy,”
¹²
I would argue that the rational norm is haunted by signs of incompleteness, inconsistency, and conflict.