Bipolar Expeditions (49 page)

5. Latour,
Science in Action.

6. Horwitz,
Creating Mental Illness,
57–77, describes in useful detail other factors that influenced the development of DSM-III and its later entrenchment: the role of lay mental health advocacy, increasing development of psychotropic drugs, and increased funds for research into biomedical causes of mental illness.

7. Silverstein and Urban, “The Natural History of Discourse,” 1.

8. Rose,
Inventing Our Selves,
105. Emphasis in original.

9. Ibid.

10. The philosopher Martin Heidegger described the loss of this kind of knowledge as “un-being” or “the abandonment of being.” Under the impact of technology in the modern age, he thought that many things come to be seen as resources that can be improved or produced according to machine-like standards of efficiency, losing their connections to contexts of meaning in the process. See Guignon,
The Cambridge Companion to Heidegger;
Heidegger,
The Basic Problems of Phenomenology.

11. In the Arcades Project, an archive of materials Walter Benjamin collected to elucidate the relationship between the onset of modern commercial developments and culture in nineteenth-century and early twentieth-century Paris, an important theme is the “interior.” With the rising importance of the bourgeoisie, novel kinds of domestic architecture and furnishings came into being as domestic life became a secluded shelter from the dangers of the marketplace. In elaborately designed and decorated interiors, new kinds of intimate family life arose. In Benjamin's words, “To live in these interiors was to have woven a dense fabric about oneself, to have secluded oneself within a spider's web, in whose toils world events hang loosely suspended like so many insect bodies sucked dry. From this cavern, one does not like to stir”
(The Arcades Project,
216). Benjamin refers to the “traces” people left of themselves in these spaces, traces that were left on the surfaces of interior furnishings. Thought about in this light, the proliferation of coverings for furniture—antimacassars—characteristic of the age, can be seen as materials to capture tracings as well as to ward them off. “The interior is not just the universe but also the
átui
[a small, decorated box to hold useful items] of the private individual. To dwell means to leave traces. In the interior, these are accentuated. Coverlets and antimacassars, cases and containers are devised in abundance; in these, the traces of the most ordinary objects of use are imprinted. In just the same way, the traces of the inhabitant are imprinted in the interior” (9).

12. John Searle, Jacques Derrida, and Judith Butler, among others, have generated a large and contentious literature about the way performatives work. See Searle,
Speech Acts.
(For references to Derrida and Butler, see below.) For anthropological purposes, I think the agreements among these writers are as significant as their differences. For an application to Mayan languages with rich implications for anthropology generally, see Hanks,
Language and Communicative Practices.

13. Butler,
Excitable Speech,
51. Emphasis in original.

14. Butler,
Bodies That Matter,
163, 232.

15. Butler,
Excitable Speech,
163.

16. Of particular interest to anthropologists, a major burden of Austin's book, and of other work in the orbit of the late Wittgenstein, such as G.E.M. Anscombe's
Intention,
was to question the link between the meaning of language and an “inward and spiritual act,” an “inward performance.” Indeed Anscombe's volume on intention is centrally a detailed exposition of how “intention” and interior mental performances must be disarticulated: “you cannot take any performance (even an interior performance) as itself an act of intention; for if you describe a performance, the fact that it has taken place is not a proof of intention; words for example may occur in somebody's mind without his meaning them. So intention is never a performance in the mind, though in some matters a performance in the mind which is seriously
meant
may make a difference to the correct account of the man's action—e.g., in embracing someone. But the matters in question are necessarily ones in which outward acts are ‘significant' in some way”
(Intention,
49; emphasis in original). The relentless message of both Anscombe's and Austin's work is that the meaning of linguistic acts is not necessarily connected with interior mental events. Even the meaning of mentalistic terms like “intention” does not necessarily entail an interior mental event. Both theorists seek to ground meaning in social use and context, human activities that are public and conventional, governed by communities of language users. This argument has been downplayed in the subsequent critique in literary theory. Derrida, for example, in his “Signature Event Context” argues that utterances are performative because they are “citations” of previously established social conventions: “Could a performative utterance succeed if its formulation did not repeat a ‘coded' or iterable utterance, or in other words, if the formula I pronounce in order to open a meeting, launch a ship or a marriage were not identifiable as
conforming
with an iterable model, if it were not then identifiable in some way as a ‘citation'?” (18). So far this would not find much resistance in Austin's account of performatives. Derrida goes on to assert that his focus on iterability extends performative language to cases where “intention” is not present. He asserts that for Austin “conscious intention would at the very least have to be totally present and immediately transparent to itself and to others, since it is a determining center
[foyer]
of context” (18). Derrida's shift to iterability allows speech acts to be performative even though “the intention animating the utterance will never be through and through present to itself and to its content” (18). Derrida's quarrel with Austin is in part over the role of the “originating will” in the performative: an utterance like “let there be light” brings something into being through the power of a subject's will. In effect, Derrida asserts that any linguistic sign can be detached from the context in which it was produced and inserted, “cited,” in another: “Every sign, linguistic or nonlinguistic, spoken or written … can be
cited,
put between quotation marks; in so doing it can break with every given context, engendering an infinity of new contexts in a manner which is absolutely illimitable.” Derrida loosens the connection Austin wanted to make between performativity and prior social conventions (12). I have found Benjamin Lee's parsing of this argument very helpful. See his
Talking Heads,
42–65.

17. My research did not delve into the political activities of these organizations, such as the Depression and Related Affective Disorders Association or Depression and Bipolar Support Alliance. Nor did I engage with members of the various organizations within the antipsychiatry or critical psychiatry movements. Outside the United States, a particularly instructive organization is called the Hearing Voices Network. It is an organization of people who “hear voices” in England, Europe, and Australia, which has been described in useful detail in Blackmun,
Hearing Voices.
If one were to think about what it would take for patients to engage vigorously with the terms of medical understanding, a useful comparative case is described by Steven Epstein in
Impure Science.
Epstein chronicles how grassroots publications and treatment activists challenged not only the medical and social services' provision of care for HIV but even the scientific terms in which it was understood. They opened the door to some heretical views of the causation of AIDS and influenced drug development, approval, and pricing.

18. Karp,
Speaking of Sadness.

19. As the linguistic anthropologist William Hanks puts it, “Where practice approaches break definitively with speech act theory is in their insistence that performative effectiveness does not depend upon the preexistence of conventional speech act types. Instead it is an emergent feature of practice, an unavoidable part of talk under conditions of differential power, authority, and legitimacy”
(Language and Communicative Practices,
236).

C
HAPTER
6

1. The often unspoken assumption that drugs work on the brain is part of the biomedical model of mental illness that is currently pervasive in the United States. The anthropologist T. M. Luhrmann powerfully articulates a concern that seeing mental illnesses as simply biological will leave patients with a lesser sense of worth. In a simple biomedical model, patients with mental illness are found wanting in the moral core where their rational intention resides. If they are incompletely curable, they will be thereafter less than a fully fledged person. This concern is exacerbated when, in the society as a whole, psychiatric illness comes to be understood only in terms of the biomedical model, at the expense of the interactional terms of psychotherapy. See Luhrmann,
Of Two Minds,
284–85.

2. For reasons of confidentiality, I have assigned pseudonyms to brandname drugs on whose accounts my interlocutors worked directly.

3. Francomano, “DTC Advertising: A Matter of Perspective”; Holmer, “Direct-to-Consumer Prescription Drug Advertising Builds Bridges between Patients and Physicians.” See also Hollon, “Direct-to-Consumer Marketing of Prescription Drugs.” This article presents both sides of the debate over whether DTC ads contribute to the public good by informing people of products that can benefit their health, or detract from it by increasing consumption of prescription drugs in ways that do not benefit patients.

4. See “DTC Advertising Spending Increases.” Also useful is “Advertising: The Cause of High Drug Costs?” The trade publication
Pharmaceutical Representative
(from which the two above-cited sources are drawn) reported on studies by the National Institute for Health Care Management (NIHCM) Research and Educational Foundation. According to the NIHCM, “Spending on mass media advertising for prescription drugs reached $1.8 billion in 1999, up from $375 million in 1995. It continued to accelerate in the first four months of 2000, reaching $946 million for the period, 58% more than the $597 million spent during the same four months in 1999” (“DTC Advertising Spending Increases”). Antihistamines took the largest proportion: 10.2 percent of all expenditures on DTC advertising between January and September 2000. See “Spending on Consumer Ads up in 2000.”

5. Elsewhere I have discussed the concept of pharmaceutical “side effects” and its impact on patients. See Martin, “The Pharmaceutical Person.” Adriana Petryna has shown that the growth in “the number of people participating in and required for pharmaceutical clinical trials has become massive” (“Drug Development and the Ethics of the Globalized Clinical Trial,” 5). The side effects Giosa is talking about are discovered through large clinical trials. Many of these new trials are being conducted in lowincome countries where people are, therefore, relatively willing to participate in trials for monetary compensation. Moreover, such subjects are much less likely to complain about side effects. Many other forces are also pushing this expansion: the post—World War II boom in production of pharmaceuticals in the United States, the increase in government regulation and oversight of the industry in the United States (including the ban on use of prisoners for clinical trials in the 1970s), and “treatment saturation” in the United States. “Treatment saturation” means that the affluent people in the United States are using so many drugs that drug-drug interactions interfere with the ability to recruit subjects for these trials. Hence, clinical trials have increasingly been conducted outside the United States. For more on clinical trials and other global aspects of pharmaceutical marketing, see Petryna, Lakoff, and Kleinman,
Global Pharmaceuticals.

6. “Psychotropic Drug Market Grows”; “Prescriptions Soar for Psychotropic Drugs.”

7. Pincus et al., “Prescribing Trends in Psychotropic Medications,” 526, 529. Figures from 1990 and 1999 are from IMS Health, courtesy of Nikolas Rose.

8. C. Lutz discusses the “inherent irrationality of emotions” in Western cultural categories: their association with danger, chaos, immaturity, vulnerability and lack of control (“Emotion, Thought, and Estrangement,” 291–94).

9. Kiki, “James! Help! My Pdoc Doesn't Know about Neurontin.”

10. Jamison, Gerner, and Goodwin, “Patient and Physician Attitudes toward Lithium.”

11. Jamison,
An Unquiet Mind,
91–92.

12. Ibid., 6.

13. Marilyn Strathern connects the advantage that is currently gained by specificity in pharmacogenomics to Western cultural concepts of the “whole person” (“The Whole Person and Its Artifacts”).

14. “Trying Topamax and Klonopin.”

15. “I'm New Heres an Intro [sic].”

16. “Cocktail Hour.”

17. An employee in a firm to which pharmaceutical companies outsource their publications graciously gave me a password to the forum. The location of the site is confidential.

18. Joseph Dumit gives an illuminating description of the emergence of a notion of “pharmaceutical normalcy,” in which health is precarious and can be achieved only through continuous ingestion of multiple drugs. See Dumit, “Drugs for Life.”

C
HAPTER
7

1. Raymond Williams used the concept of structures of feeling in order to point beyond formal beliefs or systematic world views to some range of meanings that are “actively lived and felt.” Structures of feeling involve “impulse, restraint and tone”; they involve “thought as felt and feeling as thought”
(Marxism and Literature,
132). For Williams, structures of feeling are parts of social experience that are still in process and therefore are not as clearly recognizable as when they are, if they ever are, built into institutions in a formal way. For example, conventionally, early Victorians believed that poverty and debt were caused by deviance and individual failure. Literary figures like Charles Dickens and Emily Bronte developed a new structure of feeling—a sensibility—in their novels by linking poverty and debt to the unequal social order instead. This structure of feeling was communicated through emotional relationships in concrete stories rather than in a general theory, and it lay outside conventional understandings (134).