Introduction

It is undeniable that people experience distress. How both the nature of the distress and the experience of it come to be understood is contingent on multiple factors including social, cultural, economic, gender, and spatial conditions of the time in which it is theorized. The discourses, practices and technologies that support and naturalize particular meanings of distress shift through time and place acquiring and losing meaning. During the 19th century, then again during the mid and later 20th century, the concept of “true” insanity, understood as mental “illness”, was conceptualised as biochemical, corporeal and etiologically explainable (Horowitz 2002; Hacking 1995), while “moral” insanity has, until the late 20th century, been identified as a moral disorder of behaviour reflecting the social maladjustment of the individual (Busfield 2002; Micale 1995).

Historically “bi-polar” (or manic-depression as it was once known), along with “schizophrenia”, was considered  true “insanity”, while “borderline” grew out of conceptualisations of hysteria (Micale 1995), psychopathology (Lunbeck 1994) and moral insanity (Busfield 2002; Horowitz 2002). Interestingly though, both were originally viewed as somatic difficulties and it wasn’t until the late 19th century that psychical processes were even considered as the seat of the distress (see for example Micale, 1995). Through the processes of disciplinary creation of both psychiatry and social work (see Lunbeck 1994; Figert 1996), western conceptions of distress moved to define more substantially the behaviours, processes, and treatment ideologies that identify “illness” in order to create a “psychiatry of the everyday” (Lunbeck 1994, p. 46). This psychiatry, with its desire to be viewed as a medical specialty, introduces “mental health” as a conceptual tool to define, regiment, and control social performances of distress (Lunbeck 1994). Under this medicalized gaze, behaviours of everyday living increasingly come to be evaluated and judged, creating a new category of persons not mentally ill but neither mentally healthy (Lunbeck 1994).  As distress comes to be understood through the ever more specific discourses of psychiatric illness/disorder, the practices of psychiatry have increasingly focused on the administration of populations, subjects and the restoration of the subject’s “capacity to cope” (Rose 1996, p. 12).

The blurring of boundaries between illness and behaviour, between normal and abnormal, “true” and “moral” gains momentum during this time of significant economic, societal and cultural change and psychiatry as a discipline struggles between a dynamic inclusion of the “normal” in its gaze, and a diagnostic discipline seeking to reinvest itself with the legitimised mantel of science (Lunbeck 1994; Horowitz 2002). Socially, it is also a time when “personality comes to predominate over discourses of character” (White and Hunt, 2000, 101), a predominance predicated on the shifting emphasis from socio-moral priorities, that is a focus on maintaining the individual’s moral obligations to the society within which s/he lives, to autonomist, individualist striving that values personal “growth” and accomplishment. Moving from a character base that focuses on one’s social conformity, a personality-driven social structure emphasises “the quest for a unique self” (White and Hunt, 2000, p. 95).   Within this shifting social structure, many conceptualisations of distress are theorized. Some locate distress within social relations and expectations (Micale 1995; Frank 1995), some see them as resistance or complete adherence to engendered norms that are incommensurate with individual being (Figert 1996; Gremillion 2003), some as punitive action because of a refusal to adhere to these same norms (Showalter as cited in Micale, 1995, p. 76), while others, mostly from the medical field, locate the distress in the individual as a “malfunctioning brain” (Rose 1996, p. 7).  And while particular conceptualisations predominate over others during certain historical periods, understanding distress remains open to a critical theorising that foregrounds the historicized and normative nature of its object of view. This is a critical theorisation that recognises its criticisms come from “the ideals and tensions of the society itself” (Young 1990, p. 6).

In this paper, I look at a variety of theoretical conceptualisations of “illness”, particularly “mental illness”, with a view to potentially using these conceptualisations to understand the further refined concepts of “bi-polar disorder” and “borderline personality disorder”. Following Butler, I use the concepts of “bipolar” and “borderline” (the BPDs) in quotation marks, not to make them appear any less real or negate the distress of the individual performing such things, but to trouble the naturalization of these concepts in western culture (Butler as cited in Butler and Scott 1992).  In addition, for the remainder of this paper I do not use the term “disorder” in conjunction with “bipolar” and “borderline” as the term is loaded with particular values and a modernist view about a “world that ought to be orderly” (Hacking 1995, p. 17). I hope that through this troubling of the assumptions of cultural thought around the BPDs I can work on the “limits of what is thinkable, extend those limits and enhance the contestability of what we take to be natural, inevitable about our current ways of relating to ourselves” (Rose 1996, p. 2) and others.

Beginning with the a look at the relations between illness and citizenship in order to frame my thinking, I then try to tease apart several ways of looking at illness including biomedical concepts and their critics, social constructionist, feminist, Foucauldian, and postmodernist theorisations in order to understand the range of thought given to distress. This slow movement allows an investigation of whether a theorisation of distress as performance, one premised on neo-liberal notions of the “good” citizen, allows a critical re-thinking of hegemonic and naturalized notions of “mental ill health” (White and Hunt 2000; Young 1990, p. 45).

Illness, Behaviour and Citizenship

Viewing the changing interpretation of behaviour through the technologies of the “psy” sciences, conceptualisations of distress highlight a historical shift from badness, immorality, or delinquency to psychiatric disturbance (Busfield as cited in Bendelow 2002, p. 156) and link strongly to changing notions of citizenship in contemporary thinking (Rose 1996; Young 1990; Fraser 1989). This shift in thinking from bad to mad to incompentent or dependent remains a moral valuation through the separation of illness from behaviour (Akiskal 2003) and determines whether or not “citizenship” and its benefits are bestowed on individuals (Young 1990, p. 54). Stoppard (in Ussher 1997) points out that, western cultures have increasingly come to value interiorized emotionality over a more expressive and external emotionality. This move to a social preference of an interiority of emotion coincides both temporally and conceptually with changing notions of citizenship and the conflation of these two contextual pieces opens a space for the consideration of distress, particularly as identified by the BPDs, as a performance engaged within the constraints, obligations, rights and responsibilities of the neo-liberal citizen.

Rose (1989:1999) demonstrates that citizenship within “advanced” liberalist societies is performative, a set of repeated and stylised acts of “free but responsibilized choice in a variety of private, corporate, and quasi-public practices” (p. xxiii), one that engages the “citizen” in the continual self-work that ensures that “life is to become a continuous economic capitalization of the self” (1999, p. 161). This citizen performs as the independent, autonomous and risk-assessing entrepreneur. Rose describes this citizen performing their obligations of consumption and self-mastery within a governing teleology that emphasises the inculcation of acceptable ways of performing within a market-driven culture. Consumerist action becomes naturalized as a notion of freedom and the idea of citizen changes from historical member of community with the ability to exercise political power and the obtaining of civil rights to one of an independent individual exercising freedom through the economic market-place (Rose 1989:1999, p. 124; see also Laurie and Bondi 2005, 5-6). The idea and determination of dependence, as anti-thesis to this active entrepreneurial and consumerist citizen, then, becomes one mechanism through which these citizenship ideals can be denied (Rose 1996, p. 7).

Young (1990), while extrapolating a “politics of difference”, reveals that liberal citizenship theories deny citizenship to those individuals the reigning culture deems as having questionable reason or those who are not seen as independent (p. 54). As “[d]ependence in our society…implies, as it has in all liberal societies, a sufficient warrant to suspend basic rights to privacy, respect and individual choice” (p. 54) Young suggests that the exclusionary practice of denial of citizenship hides in contemporary notions of health.

White and Hunt (2000) explicate a notion of citizenship predicated on a neo-liberal context that values autonomy, independence, and engagement with market driven ideals of risk taking. This context naturalizes self-government as a practice of care of the self, and thus as a practice of freedom. The ethical practice of care of the self in addition to a concern over the conduct of others “influences the extent to which individuals are recognized to be competent members of a political community and, thus, citizens” (p. 95). Intimately tied to notions of freedom and linked to a relational model of governing, the actions sought through various performances are both self-governing and other-governing but are understood through normative frameworks (Hunt 1999). Underlying conceptualisations of these performances are moral notions that involve normative judgements. For example, manipulative performances by individuals linked to the BPDs are pathologized and often punished while similar performances enacted within the sphere of the market-economy and that lead to an increase in financial benefit are not. Thus discourses of economic participation are embedded in the definition of dependency but are masked by the strong language of health and illness.

This different perception may lie in the assignment of dependence (illness) but is also a fundamental link back to the constitutive, performative nature of distress. In faint echoes of Szasz's (1960) criticism of the moral yet unaddressed nature of psychiatry, Hunt (1999) notes that “moralizing discourses are frequently linked with other discursive components such as concern with national decline and with individual and collective health” (p. 14), and reveals that moral regulation movements are increasingly and disproportionately existing within discourses of health (p. 3). The determinancy of dependency through the discourse of health as a moral movement appears sufficient and necessary to the negation of citizenship through a performance of distress. In contrast to a concept of citizenship that prefers a particular ideal of care of the self, Orsini (2005) discusses a notion of biological citizenship through which individuals form political identities as a partial resistance to the  “official knowledge” (p. 1) of health. These personal, contested notions of biological citizenry provide some way to view, with a lessening pessimism over the apparent inescapability of it all, a way to affect agency from within a prevailing ontological and epistemological discourse. As a way of revealing the power structures inherent in the discourses of health that deny citizenship, these resistances show how citizenry is both “a powerful instrument for reinforcing or altering particular programmes of competing political interests” (Fierlbeck 1991, p. 3) and a way of challenging it. Biological citizenry, according to Rose and Novas (2004, cited in Orsini), enables individuals to frame their health demands as political while maintaining their identity as citizens of the society within which they perform. This conceptualisation of citizenry is active and participatory, and links politics to individual “biological destiny” (Orsini 2005, p. 11). In direct contrast to a neo-liberal, market-driven citizenry engaged in the practices of care of the self within a consumerist frame, biological citizenry uses the body as the foundation upon which political demands are made and active citizenry is housed. Taking on what appears as a solely materialist attitude, biological citizenry “changes…how citizens construct their citizenship duties or obligations” (Orsini, 2005, p. 31) through the implication of the body, ill or otherwise, as a politicised experience. Unfortunately, as Orsini notes, the focus on the body runs the risk of masking or negating the social context through which this experience is made understandable and thus runs the risk of neglecting systemic social inequalities. Biological citizenship appears, then, to accept a universalised notion of the “healthy” body thus creating spaces for communities of “ill” bodies to coalesce and form political collectives. Unlike Moss and Dyck’s (2003) conceptual triangulation of body, mind, and space, which moves the gaze outward from the individual onto the social, biological citizenship reifies the location of distress in the individual body while challenging the social and moral underpinnings of determinations of citizenship rights and obligations.

A performative conceptualisation of distress provides a stage upon which the context of the good citizen, and its inculcation and reiteration through the mechanisms of dominant psychiatric discourses, plays out. People performing “bipolar” or “borderline” destabilize ideas of being and knowing but in differing ways. “Borderline” challenges dominant social norms for economic participation (inability to keep a job, home etc.), self-government (emotional lability), bodily care (as in the case of self-mutilation), and relational/familial expectations (history of stormy relationships), while “bipolar” traverses the extremes of energy. Some of these traverses are viewed in a positive light (for example the extraordinary ability to work excessive hours on little sleep, being the “life” of the party etc.), while others such as the total removal of oneself from the social arena in depression (see for e.g. Healy 2006; Simmie and Nunes 2002) are pathologized

This stage and the performances that it displays are, however, conceived in many different ways. These ways, or conceptual frameworks, are what I move on to next in order to tease apart ideas of distress and how they may express define, or maintain, implicitly or explicitly, neo-liberal ideas of citizenry.

Biomedical Concepts and their Critics

Of the many conceptual positions that are used to theorize distress, biomedically-based psychiatry currently occupies the hegemonic position (Double 2002). In bio-medical theories, including bio-psychiatry, the physical body is the primary site of investigation. While its role in both the constitution and social acceptance of normative criteria for determining the healthy or ill body is not unproblematic (see for example Dale 2005), this anatomical conceptualisation of illness emphasizes an observed deviation from a medically-devised understanding of the structural integrity of the body (Szasz 1974, p. 210) and places the location of the “illness” within the body (Lorber and Moore, 2002, p. 2). Western cultures have naturalized this conceptualisation as value-free science. The critically contested nature of these concepts, concurrent criticisms of the value-free status of science and the negation of the experience of those so distressed, tend to have little impact on the practice of psychiatry (Wilson and Beresford 2002).

Current understandings of distress located within the bio-medical (often called neo-Kraepelian) framework focus predominantly on the biological brain, as is evidenced by theories of  “chemical imbalance” as the causal feature for mental illness (Double 2002). This particular framing of distress satisfies an aetiological urge (chemical imbalance), identifies a biological site of the “structural” failing in the brain, and provides an ameliorative treatment (typically pharmaceuticals). Through a prescriptive process, it legitimises the experience of individuals in distress by naming their experience within a socially accessible grid of intelligibility and by providing a solution. Seeking out cause, prognosis, and cure within the physical anatomy (hormones, genes, chemicals, etc.) of the individual through tests and palpable signs, the bio-medical discourse maintains the modernist, positivist view that scientific methods are objective and can ultimately lead to a universalizable truth (Thomas and Bracken 2004). Critics of this particular framing of distress are typically placed in three camps: anti-psychiatry, critical psychiatry, and increasingly, post-psychiatry.

Thomas Szasz, the outspoken psychiatrist of the anti-psychiatry camp, states that mental illness is a “myth, and that the psychiatric “creation” of “mental illness” as a medical concern required a change to the definition of “illness”. He claims that to “the established criterion of alteration of bodily structure was now added the fresh criterion of alteration to bodily function” (Szasz 1974,p. 12 emphasis original). As bodily structure was an anatomical observation, behavioural observations required a shift in medical thinking in order for those observations to be considered within the health/illness paradigm.  Szasz’s claim that because a “symptom” or “behaviour” is evaluated within a particular social context, the term “illness”, as a structural failing of the anatomical body, does not apply. That is, the norms from which the individual deviates are behavioural thus they are socially, not biologically, determined (Szasz 1974, p. 201) and as such bio-psychiatry had to redefine the term “illness” to make mental distress fit. Instead of theorizing distress as illness, Szasz defines the behaviours as indicative of “problems with living” (1960). Identified through a label of mental “illness”, “problems with living” do not refer to the structural integrity of the human body but are, for Szasz, deviations from social, legal and ethical norms.

In writing against psychiatry’s disciplinary reliance on psychodynamic methodologies while claiming the anatomical concept of illness [1], Szasz [2] criticises a psychiatry that both denies its companionship with linguistics, in that it works in the world of signs and signifiers through the investigation of “sign-using human behaviours” (1974, p. 4) while at the same time claiming companionship with medicine through its search for bodily cause and structural failing. Szasz classified psychiatry as a “theoretical science” studying personal behaviour (p. 8) and, as such, dealt with moral, not physical, issues. His revelation that the moral foundation of psychiatry becomes shrouded by the use of anatomical implications highlights the adaptive nature of the discipline. He claims that obscuring the individual’s “problems with living” by calling it “mental illness” has served to distract the discipline’s attention away from the “essentially moral and political nature of the phenomenon” (p. 25) while highlighting the individual response to it. Biomedicine’s positivism dismisses the qualitative aspects of problems with living, preferring “scientific” methodologies and the norming (or quantifying) of “health” as the pre-eminent goal.

While the “anti-psychiatry” movement was evident mostly in the 1960’s and 70’s, current critical examinations of psychiatric thinking, processes, and assumptions are labelled (or claim the label) critical psychiatry or post-psychiatry. The goal of critical psychiatry is to avoid the polarization of the psy/anti-psy movements while attempting to engage practicing psychiatrists in an examination of several foundational aspects of bio-psychiatry: first that the modernist set of assumptions on which bio-psychiatry is based, the “nature of mind, meaning, and knowledge” (Thomas and Bracken 2004, p. 368) are not universal truths but instead theoretical conceptualisations imbued with social and historical signification; second, that individuals in distress and governments who typically pay for services are demanding more input into the nature and content of psychiatric services including an expansion of the narrow focus on anatomical concerns; third, that the experiences of individuals in distress have inherent value and their expertise and should be engaged; and finally, that both corporate desire to control the mechanisms and responses (i.e. pharmaceutical interventions) to perceived ill-health and the coercive tendencies of psychiatry should be monitored and managed. (Thomas and Bracken 2004, p. 368). This current conceptualisation does not challenge the illness designation as had Szasz but instead accepts this critical foundational stone and tries to mediate the nature of the power/knowledge relationships within the “psy” disciplines. Through the inclusion of individuals and their experience, critical psychiatry manages at once to recognize the socially and historically constituted nature of the definitions of “illness” while at the same time obscuring the naturalized nature of the term. It both challenges and reinforces the idea that what individuals experience is illness, and as such appears to contest the foundations of biological psychiatry as hegemonic. While it operationalises a different power/knowledge relationship between individual and psychiatry, it maintains the naturalized ideal of mental “health” vs. mental “illness” and engages individuals to do the same (Thomas and Bracken 2004).

While anti-psychiatry is, today, largely dismissed within disciplinary boundaries (Double 2002), critical psychiatry has had some impact. Bio-psychiatry seems to be responding to critical psychiatry’s alternative theorization by linking neuro-psychiatric and bio-chemical theories of mental “illness” (see for example Price, Adams and Coyle 2000). Biological psychiatry attempts to address the “structure/function” problem through a  rethinking of the physical/structural bodily processes, in this case through the medical specialty of neurology and the behavioural body as observed through the practices of psychiatry.  Price, Adams and Coyle (2000) state “human cognition and behavior are now understood as emerging from the complex interplay between brain structure and social forces” (p. 5). Coming full circle from the separation of social, moral, and psychodynamic theories from the biological (see Horowitz 2002), biomedical psychiatry attempts to inhabit both camps; the anatomical and the social. Structural integrity of the body and the functionality of the body demonstrated through behaviour are merging under the disciplinary mantle of neuropsychiatry. This amalgamation of structure and functionality, however, remains predicated on the natural sciences, and gives “[c]lassifactory thought…an essential space” (Foucault 1973:1994, p. 9). Western psychiatry relies on this essential space of classification to define not only illness but also, conversely, health (Millon 1996, p. 4). A health/illness dichotomy, however, leaves little room for degrees of health or illness and gives particular framings of health preferential ontological status (Moss and Dyck 2003).

These bio-medical approaches assume that biologically constructed concepts are ahistorical and asocial. In conceptualisations of “bipolar,” the inability to regulate emotion in expected ways is predominantly viewed as being caused by an ill brain rather than purposively performed, while for “borderline” causality is obscure. “Borderline” behaviour is often viewed in the medical community as chosen and purposely performed, thus not illness and not afforded the same level of “care” (Wirth-Causten 2003). “Bi-polar” in this matrix is a body with structural failing, a failing currently of the chemistry of the brain. “Borderline” in this same matrix is currently linked to a functional failing of the structure of the personality (Millon and Davis 1996, p. 4).

Classification matrices, such as the DSM IV and the ICD 10, constitute psychiatry’s Foucauldian grid of intelligibility (McWhorter 2004, 153) and promote two assumptions: first, that a grand theory of health determined through positivist rigour can ultimately explain/contain distress; and, second, that distress, in its myriad forms, is pathological. Additionally, in order to account for scenarios outlying the contemporary classification matrix, the grid maintains a plasticity that enables it to shift and redefine contradictory or inexplicable behaviours through revisions to current criteria, the creation of new classifications, or, in the case of many personality disorder classifications, a dismissal of the behaviour as patient resistance.  Current clinical research, while acknowledging the evolving conceptual nature of both “bi-polar” and “borderline”, reveals an unclear relationship between the diagnoses while identifying that they are now often given concurrently to individuals (Akiskal 2004; Magill 2004; Akiskal 2003). This linkage ends what has been centuries of division between the “true insanities” and “moral insanity” (Micale 1995; Horowitz 2002).Ussher (2000) states “the development of new technology for calibrating the body will undoubtedly lead to a new set of meta-theories for women’s madness” (p. 212), as new ways of “seeing” the body lead to new theories on how to evaluate its behaviour. Regardless, in this positivist reductionist conceptualisation, distress is ultimately used as evidence of some kind of deviation from the norm, and “is construed as an individual problem” (Ussher 2000, p. 211).   As McWhorter (2004) states these grids of intelligibility are complex and comprised of networks of knowledge, institutional practices, public policies, as well as social and political power (p. 153). Attempts to universalise performances of distress through increasingly detailed lists of normative criteria and increasingly fine delineations between categories show that the strength of the classificatory process is its ability to widen or narrow depending on its object of view, the purpose of that view, and socio-cultural evaluations of the “object” in question. Through the use of detailed diagnostic criteria, the totalising power of biopsychiatry, that is its ability to ultimately capture most if not all of human mental experience within its framework, is revealed (Foote and Frank 1999; Lunbeck 1994).

Constructing Power and Illness

In response to positivist positions, other theories have emerged to shift the focus from the individual as the object of attention to socio-historical discourses that structure the nature of our knowledge. Social constructionist framed theorisations are critical examinations of the limits and conditions constituting claimed objectivity in positivist research. Szasz’s moral implications are revived, problematized and shifted through diverse conceptualisations that evolve contested positions as a modus operandi. Under the broad rubric of social constructionism, critics from feminism, disability studies, and geography, among others, have deconstructed the inherent assumptions and frameworks of the positivists to reveal their historicized nature. Through the inclusion of the social as a viable research object, constructivist theorizing demonstrates how normal is defined through the definition of the abnormal revealing that these categories are neither naturally occurring nor ahistorical.

Michel Foucault’s work has been influential in the movement away from individualized and ahistorical theories and two of his main theorizations, the nature of power and the nature of government, prove very helpful in our examination of distress. Foucault (1978:1990) conceives power as productive and not held but exercised in relation. Power is present in the discourses, technologies, mechanisms, and practices of disciplinary structures and is complicit in the creation of knowledge. He also makes clear that this notion of power is predicated upon the existence and potential exercise of resistance in those same relational spaces.  His method for investigating power relations occurs through an analysis of the “how”; that is how do certain power relations “structure the field of other possible actions” (Foucault as cited in Dreyfus and Rabinow,1983, p. 343) and how these relations become invested in particular institutions.  This investigation of the “how” allows us to move distress away from the individualized pathological and situate it instead within complex power/knowledge relations that shift, and within which individuals can understand, accept, challenge and resist existing norms and structures.

In addition to this theorization of power, Foucault’s reconceptualization of government as the conduct of conduct, both self-government and other-government, is important as an alternative understanding of why bio-medical conceptualisations focus so strongly on the anatomical individual. By naturalizing a model of self-government whereby the individual inculcates the idea that self-monitoring, risk assessment and management, and self-care is the paramount duty of citizens, governments can “govern at a distance” (Foucault 1978:1990; Rose 1996). This governing at a distance allows the state to promote particular goals geared towards social control all the while concealing the operation of power to achieve those goals. Citizens, in effect, come to value the goal and naturalize it as a desirable way of living.  Foucauldian theorizations broaden the landscape of what is acceptable to be studied from the narrow focus on the “subject only” to those processes that work to create the subject, as we know it. Critics of this way of theorizing point out that what is lost in the focus on the social is the experience of the body, the pain, discomfort, and challenges engaged/experienced when a biological function is significantly impacted by disease, accident, malformation etc. (Moss and Dyck 2003; Ussher 2000; Micale 1995). The embodied experience of the individual in some social constructionist theorising is downplayed in order to highlight the cultural, social, spatial, or architectural constructions of a particular society’s normative idea of how a body should be (see Bickenbach in Jones and Basser Marks, 1999). While other scholars, interested in highlighting the discursive nature of being (see Butler 1990; Sawicki 1991; McLaren 2002), emphasize how Foucault can be useful in investigating the contingent, constructed, and relational nature of power and advance his theories through to considerations of the body as an identified direction for future work.

In investigating “multiple personality disorder” (MPD), Hacking (1995) provides an interesting example of constructionist theorizing. In taking apart the conceptual matrix around MPD, Hacking reveals how certain performances of distress are defined through normative ideals of what “personality” is and how disciplinary guidelines teach physicians to see certain performances in certain ways. He uncovers the how the naturalization of views of distress become ontological entities, that is seen as individualized ways of being, instead of epistemological theories of how we come to understand the distress of the individual.

From early treatises on hysteria, Hacking (1995) shows how biomedical research implicates social conditions in the appearance of distress but “never propose[s] that the [social condition] itself, and its causes, should become an object of scientific study” (p. 59).  By maintaining a sole focus on the individual, Hacking demonstrates how positivist theorizing determines what is considered a viable object for research and how other variables, such as the social nature of the definition of illness, are dismissed. He demonstrates how, through the inclusion of a theory of social causality, the determination of object of study can shift. Problematically however, Hacking demonstrates that even the inclusion of the social can have the effect of a redirected gaze on the individual by explaining the cause of distress but leaving that cause unresolved.  An external (that is non-anatomical) cause is identified, but the focus of work remains individualized.

wevHo By deconstructing how disciplines are trained to see, trained to integrate outlying experience or expression, and trained to speak about the concepts that support their work, Hacking shows us that taken for granted concepts are not natural. There is a great deal of effort required to maintain the integrity of a theory and this work is firmly lodged within the disciplines that use them. This constitutive aspect of disciplinary work, that is, being constituted by theories while in turn constituting those very theories, is vital to understanding why constructionist theorizing is important. A constructivist perspective uses deconstruction “. . . not to negate or to dismiss, but to call into question and, perhaps most importantly, to open up a term . . . to a reusage or redeployment that previously had not been authorized” (Butler and Scott, 1992, p. 15). The socio-cultural-political nature of concepts such as gender, sex, and, in this case distress and the BPDs “[produce] and [regulate] the intelligibility of the materiality of bodies” (Butler and Scott, 1992, p. 17, original emphasis). That is, the discursive constructions of concepts are the mechanisms used to understand and create the body in its materiality. The question then arises can research account for experiences of pain, distress, and discomfort while foregrounding an implication of social context?

Embodying power and illness: Triangulating Dualisms

In order to understand bodily experience within a socially contingent knowledge base, a theoretical framing that includes both the material and the discursive proves useful. A material-discursive theorization incorporates both lived-through-the-body experience, including the social and institutional along with the corporeal, with the understanding that discourse and its social construction, shapes and legitimates what is known and told about subjects (Moss and Dyck 2003; Wirth-Causten 2003). Using a materialist-discursive theory, Moss and Dyck (2003) outline a “radical body politics” in which they focus on how the material and the discursive “aspects of the body shape, mediate, and assist women in negotiating space at a variety of scales.” (9). By acknowledging the effects of power relations on and through the body, this “politics” positions researchers to recognize the play of power within the experience of women, to both honour their experience and to gain insight into that experience.

But by defining a theoretical placement through the contradistinction of two terms is problematic. Binaristic thinking that opposes one term over the other is the basis of much modernist and positivist thinking that brings with it significant judgement and bias. Binaristic tendencies of the discourse/material are, as Moss and Dyck (2003) state, problematic in their typical negation of the second term in favour of the first. Using Mouffe’s (as cited in Butler and Scott, 1992) idea of the “constitutive outside” as the productive, reproductive, and receptive qualities of binaristic dualisms, Moss and Dyck are able to hold both sides of the binary in tension, that is to accept each as constitutive of and constituted by the other.  Moss and Dyck’s triangulation of concepts, the linking of space to the material and the discursive, allows for a gaze that extends beyond the material body and the discourses that render it intelligible into a wider field of view that incorporates the physical and social spaces through which people navigate. Holding the binaries in tension, their triangulation of concepts through the inclusion of spatiality ensures, in my opinion, that the individualizing tendencies of theorisations such as in the biomedical field (which relies heavily on binaries) are counteracted. This triangulation incorporates the social and breaks apart the binary from “either/or” to “more than/and” statements. The spatial aspect of embodiment, vital in this triangulation “refers to those lived spaces where bodies are constitutively located conceptually and corporeally, metaphorically and concretely, discursively and materially, being simultaneously part of bodily forms and their social constructions” (p. 49, emphasis in original). The social and architectural spaces in which bodies function are only part of the spatial equation: space, for Moss and Dyck, applies to both spaces of the body,and spaces in/through which bodies navigate.

Through the inclusion of spatiality, Moss and Dyck’s theorisation addresses the wider socio-cultural aspects of the phenomenon being studied and they expand the emphasis outward from the body through an understanding of space as simultaneously “a social and physical entity”(p. 15). As distress is experienced in all three conceptual arenas, a material-discursive-spatial theorizing challenges traditional biomedical binaristic thinking of health/illness or mind/body to a broader platform, one which does not prefer one concept over the other but instead allows for the relational and constitutive aspects of subject and society to be considered and held in tension. Triangulated conceptualisations such as Moss and Dyck’s, and Ussher’s as we will see, acknowledge Micale’s (1995) caution that emphasizing the “social and political agendas of medicine” merely replaces biomedicine’s fixation on the body with social construction’s fixation on the social and that both are “lopsided and distortive” (p. 132) in their negation of the other.

Ussher (2000), focusing on women’s distress and not their chronically ill bodies, chooses a different triangulation concept from Moss and Dyck. By combining the ‘intrapsychic’ with the material-discursive, she is trying to account for the ways individuals use such mechanisms as “repression, denial, projection or splitting for dealing with abuse, difficulty, and psychological pain” (p. 220-221). The intrapsychic thus operates at the level of the psychological individual. Unlike Moss and Dyck’s triangulation, Ussher’s use of the intrapsychic does not move outward from the individual to incorporate the spaces within which they navigate but instead remains focused on the  embodied and psychic space of the individual.

Rose (1998) outlines a critical history of the “psy” sciences (psychiatry, psychology and psychoanalysis) and identifies their role in the formation of a number of social factors including economic, political, professional, cultural, and patriarchal life (p. 46). Far from being technological mechanisms of societal shifts in these areas (among others), the “psy” sciences were, and are, instrumental in the very construction of those shifts. Ussher’s concept of the “intrapsychic” focuses on the individual in their distress and is foundationally, through its historical growth in the “psy” sciences, based on modernist notions of the self as independent and rational. Intrapsychic concepts such as repression or denial become individualised as a material performance of those mechanisms and evaluated as either normal or abnormal by those exercising the knowledge/power of the hegemonic discourse. The intrapsychic shifts quickly from a critical concept, one that attempts to re-historicize and denaturalise the concept of distress, to an operational one through its emphasis on working to remediate that same distress or cure the abnormal solely through work with the individual. The move between the conceptualisation and the operationalisation of theories of the intrapsychic comes in the form of therapy. The focus remains persistently on the individual. What is left out is the reversing gaze -- that is, the gaze that asks what are the conditions of the emergence of the “political, institutional and conceptual conditions” (Rose 1998, p. 45) that conceptualises distress as pathological.

In attempting to bridge the institutional regulation and treatment of “madness” with critical theorising that moves beyond the merely biological, Ussher triangulates concepts that may be operationalised as therapy in order to assist people seeking relief from distress. Even though for a significant period of time Ussher could not reconcile her awareness of alternative theorizations of distress with the medicalized model, she states that “we cannot dismiss mental health problems as linguistic constructions or mere justifications for regulatory control; we need to offer something more concrete than critique for women who come forward for help” (p. 208). She states reflexively that her work in psychology is an effort to provide that. For Ussher theorising is all well and good but her focus is on how to operationalise critical work on the conceptualisation and constitution of madness (distress) in order to assist those who are experiencing it. Ultimately, Ussher is trying to reconcile the bodily focus in biomedicine with a psychological understanding of distress and the discursive ways in which we come to understand such phenomenon. Conversely, she is also seeking answers as to why much of the critical work around distress or madness is not being taken up within the hegemonic discourses and practices of mental health/illness.

Problematically however, many socio-cultural assumptions and conceptualisations of distress as abnormal are naturalized into the fabric of psychological and psychiatric modalities, treatments, and classifications that all seek to re-normalize those accessing help. By outlining how therapy acts to normalize, surveil and discipline subjects. Foote and Frank (1999) problematize therapeutic work through their examination of grief and grieving.  Demonstrating that therapy works to bolster modernist views of health and illness in order to “heal” the division of “the normal from the pathological” (p. 160), they demonstrate that in the instigation of a “truth game that [both therapist and individual] are playing, they share the common goal of one’s being directed toward some self-truth by the other” (p. 162). They highlight that what is the goal of a therapeutic intervention is the bringing back to normality something deemed abnormal and that the “psy” sciences are the discipline responsible for demarcating that line.

The underlying conceptual critical framework of therapy, then, normalizes certain ways of being distressed while, concurrently, pathologizing others. These frameworks or modalities do not necessarily investigate the historico-politico-economic rationalities that work to construct normative ideals of behaving in the world, even though many are based upon modernist ontological and epistemological assumptions. Ussher attempts to address the positivist epistemological standpoint of “virtually all researchers or clinicians” (Ussher 1997, p. 209) in the field of distress, madness or mental illness through the inclusion of the intrapsychic as a triangulating concept. Unfortunately, using the intrapsychic to broaden the theoretical landscape does not advance consideration beyond the material confines of the individual and ultimately loses the wider socio-cultural impact on understandings of distress. Sawiki (1991) argues that focusing on psychoanalytic concepts, in order to salvage or reinvigorate discursive investigations misses the point.  For a feminist Foucauldian, such as Sawicki, the point is in asking how, in defining a certain theoretical conceptualisation, do normalizing tendencies and potential domination come into being “despite the intentions of its creators” (p. 55). Rose (1998) advances this thinking in considering that psychology “forms a part of the practical rationalities of assemblages that seek to act on human beings to shape their conduct in particular directions”  (p. 54). The political nature of the “psy” therapies in the maintenance of social norms is shrouded by its efforts to “help” the individual in distress and in doing its work, it engenders within the individual a desire to seek out that help, and incites in the social world an expectation that this desire is proper.

Traditionally, therapeutic intervention “offers to reinterpret women’s experiences to them, so that they do become tellable within male narratives” (Foote and Frank, 1999, p. 178).  Both Foote and Frank (1999) and Ussher (2000), work against traditional methods and claim that by using narrative therapeutic interventions the theoretical construct of the intrapsychic sidesteps this fit of the individual into the situation and instead works to externalise the dominant explanation, or story in narrative therapeutic language, as but one possible story to be told. Even this goal remains, however, technological, that is an application of knowledge for practical purposes aimed at re-creating (or assisting an individual to recreate in themselves) a citizen that exists in particular, culturally appropriate ways.

To make comprehensible a range of human experience, the “psy” sciences codify “the vicissitudes of individual conduct as they [appear] within the apparatuses of regulation, administration, punishment and cure” (Rose 1998, p. 61). It is through this process that the “psy” sciences, particularly psychology according to Rose, create the individual who is amenable to having those interventions enacted upon them. This amenability, even desire, to engage in therapy is what provokes Ussher out of an entirely theoretical, critical position on madness and back into a practice of psychotherapy (Ussher 2000, p. 208). For Fraser (1989) therapy is one of three apparatuses that allow for a depoliticization of experience and in fact “translate political issues” (p. 154) into personal ones. In fact, these mechanisms not only depoliticise the issues, they protect them from critical reappraisal. The socially oriented criteria of the BPDs, the social isolation, the economic non-productivity, the implications on the masculinist ideals of the nuclear family all remain unexamined. The mechanisms of the “psy” sciences categorize deviance from norms and identify individuals as sick, thus in need of state intervention. These same mechanisms also reinforce the “need” to gain a label to be considered legitimately in need of assistance in order to attend to other materially important aspects of life such as income and treatment. While depoliticising the context within which people experience distress, JAT apparatuses maintain a strong focus on the individual as citizen and act fundamentally in the naturalization of self-governing tendencies within populations.

Performing Bi-Polar, Performing Borderline

Distress may, at any one time, be seen as biochemical, socially constructed, a response to socialised oppression, or an effect of discursive technologies. These all insist on a reified notion of distress seldom questioning the politico-cultural assumptions embedded within the idea of distress itself. In order to tease out those politico-cultural assumptions, another conceptualisation lends itself to our understanding -- that of distress as performance. Micale (1995) explains that distress can be viewed, and is viewed by many non-medical scholars, as a ‘sort of social communication in the social language of the bodily symptom” (p. 112).  Distress in this sense forces illness out of the realm of strictly medical understandings and onto a cultural stage. Using the example of Madame Bovary, Micale demonstrates how cultural discourses come to mirror medical discourses and how these cultural discourses shift social practices to naturalize the site of instability as within the individual. This representational reaffirmation of a particular theorisation of distress serves a political purpose: it elaborates certain experiences as legitimate distress while implying a set of assumptions about what it means to be distressed (Butler 1990).

In attempting to problematise the taken-for-granted nature that gender holds in much traditional theorising, Butler (1988; 1990; 1993) elaborates a theory of gender as performance that produces, reproduces and maintains the very construct it performs (1988, p. 525). This theorisation proves helpful in our consideration of distress. In her conceptualisation of gender as performance, Butler explains, first, that performance is constitutive of the individual who performs (1990, p. 24). This understanding, that an individual not only performs certain ways of being but is constituted by that performance denaturalises gender from a reliance on the physical body and an identification of female or male biology. Second, that what is said about gender (gendered discourses) constitutes how it is performed (1990, p. 24). This second point argues that discursive mechanisms structure what is performed, how it is performed and understood, and how performances that outlie the framework are identified and responded to. Third, these performances form a regulatory practice (1990, pp. 31-2; 1993, p. 1) from which the response is predicated and enacted. Butler also insists that the performative constitution of gender acts on the surface of the body and not on some “essence” of being (1993, p.140); that the performance of gender is not some essential aspect of biology but instead a construction that requires specific ways of being in society. And finally, that gender is performative in the sense that it fabricates an identity that must be reaffirmed through future performances in a “stylised repetition of acts” (1993, p. 140). For Butler (1988) performance is temporal, collective, not inconsequential to the culture, and has the strategic aim of maintaining the normative notions underlying its binaristic structure (p. 526). Through this conceptualisation of gender as performative, she is able to denaturalise a concept and understand its constructed and enacted character. By deflecting the “essence” of gender from the body to the discourses and practices that constitute its social expression, Butler provides us with a new way to view distress, as performative and not as some illness or behavioural process. Especially helpful is her claim that while gender is performative and constructed in and through that performance, she is in no way asserting that it is illusory or in some way “not real” (1990, p. 32). If we consider distress as a performative act, one that becomes defined, in our case, as “bi-polar” or “borderline”, through time and strategic normalizing, then the inscription of disordered distress through these particular labels can be distanced from some modernist ideal of mental health. We see how the performative imperative of distress both constitutes the individual, so performing, as distressed, while at the same time constituting the distress categories with which certain performances are defined.

Butler’s notion of performativity and its constitutive nature are clarified further as “not a singular or deliberate ‘act’, but, rather, as the reiterative and citational practice by which discourse produces the effects it names” (1993, p. 3). The performance of distress and the discourses that name and legitimise such performances are constituted and constitutive of the other. This notion of performativity does however bring up the idea of agency. The challenge of the agency of the individual is deflected through an understanding of gender performances as not some kind of closet from which one “chooses” which gender to be today nor some imposition upon the individual (Butler 1988, p. 526) but instead the performance is an inter-relation between “text and interpretation . . . in a culturally restricted corporeal space [in which the gendered body] enacts interpretation within the confines of already existing directives” (p. 526). Distress as performance is indicative of embedded relationships among “bodies in context” in specific arrangements of the deployment of power” (Moss and Dyck 2003, p. 53), and arrangements between the individual and society formed, mediated, and defined by the discourses available.  These performances, constitutive though they may be of a particular conceptualisation of distress, act on the surface of the body akin to gender performances, and are not indicative of some essential core that is pathological.

Conceptualising distress as a constitutive performative act escapes a reductionist and bleak descent into perpetual conflict with society by viewing the performance instead as “a struggle to rearticulate the very terms of symbolic legitimacy and intelligibility” (Butler 1993, 3). That is, by viewing distress as a performance, hegemonic conceptualisations become open to examination. Not only are ideas of biology and social construction to be considered legitimate units of analysis but critical reflection on the very basis of the concepts is necessary. The idea that distress is understood through a highly politicised process geared towards the naturalisation of one concept over another (Butler 1990, p. 2) and that these politics “constitute the contemporary field of power” (p. 5) validates the political as a field for the examination of distress.

In performing “bi-polar”, actions and behaviours are seen as “out of the control” of the individual. These acts are explained through a variety of causal, etiological, or traumatic rationales and therefore labelled as “illness”. The pathologizing criteria are conceptualised as incapacity to regulate emotional states, of moving through the extremes of emotional poles. Thus, labelled as ill, the performer is disengaged from her societal expectations to perform in a certain way. The highly political desire for moderated and internalised emotion are not investigated as impacting the performer or the evaluation of the performance.   In performances of “borderline”, the pathologizing criteria are not typically viewed as affective (that is biological) but as defective adaptation strategies. These strategies are identified through economic, relational, or self-governing behaviours such as unstable relationships, unstable work histories, suicidality, self-harming, or unstable exteriorised emotions. Whereas behaviour in “bi-polar” is seen as an outcome of affective problems, affective problems in “borderline” are seen as the outcome of behaviour. Normalization ensures that “the perception that other ways of being in the body are pathological…because they do not represent a tightly controlled system” (Birke as cited in Bendelow 2002, p. 43; also see White and Hunt 2000; and Young 1990, p. 11 for a discussion of “ugly bodies”). Certain levels of “self-control” and “discipline” are expectations. In a very material sense, individuals are obliged to be “healthy”. For both “borderline” and “bipolar”, the expected ways of shaping their bodies, and the performances of distress are unexpected, disconcerting, and consistently challenge the status quo of power/knowledge relationships In effect, they challenge at a political level the very conceptualisation of distress.

A Politics of Distress

Butler (1988) states that the “transformation of social relations becomes a matter…of transforming hegemonic social conditions rather than the individual acts that are spawned by those conditions” (p. 525). A politics of distress conceptualises the performance of “bipolar” and “borderline” within the realm of debate on what is a citizen in order to redirect our critical gaze away from the individual in performance onto the social conditions within which these performances are enacted. As seen in scholarly and personal histories of distress (see for example Micale 1995; Hacking 1995), particular performances are labelled, relabelled, resisted, and discarded. This continual fluctuation reveals the “undesignatable field” (Butler as cited in Butler and Scott, 1992, p. 16) that constitutes performances of distress and problematizes a desire for universalizable and totalizable categories to define them.

Moss and Dyck (2003) explain that, in looking at women’s ill bodies, “the materiality of the body shifts unpredictably and changes the relationship between what the body can do and be and the expectations of what the body can do and be” (2003, p. 84). Following this thinking, we can further refine a politics of distress as not so much what the body can do and be but how the body does and is. This how requires an interpretive stage upon which the act is publicised. By conceptualising distress as how the embodied subject performs certain social relations compared to how it is expected to perform, we realize that the interpretation of these performances as “bipolar” or “borderline” reveals the disciplinary, social and political forces at work producing a normalized view of mental “health” as rational performance. These performances are constitutive of and constituted by the evaluations of the behaviour. These evaluations are the workings of power/knowledge.

The definition and legitimisation of the categorising and defining of distress as ultimately a mechanism for social control is evident in the study of many “illnesses” (see Hacking 1995; Micale 1995; Ussher 1997; Bendelow 2002; Lorber and Moore 2002; Davidson 2008; Gremillion 2003) but it must be remembered that these conceptualisations, as Bordo (1995) points out, can be reversed and seen as a way of investigating what is wrong with a culture. The relational nature of power inherent in performances of distress is exposed through the diffusion of  distress as merely an individual, symptomatic act, into a diverse, intermingled framework including the individual, the discursive, and the social.  My effort in this paper has been to critically reflect on conceptualisations of distress within a “politics [that] does not seek to regiment individuals according to a totalitarian system of norms, but to de-normalize and de-individualize through a multiplicity of new, collective arrangements of power” (Seem in Deleuze and Guattari 1983, p. xxi) thus revealing performances of “bi-polar” and “borderline” as political acts.

A growing politics of distress explodes constructed boundaries revealing a permeable and shifting membrane between the individual and the social. As Foucault claims however, all ideas are dangerous and this conceptualisation is no less so for wanting to incorporate embodied experience and discursive constructions as both political and performative. In “bipolar” and “borderline” tensions between the individual as self and the individual as social entity are as much embodied for the individual as embedded in the complex social relations within which they navigate. The conceptualisation of distress performances as “bipolar” or “borderline”, are evaluated through elaborate cultural systems of understanding. A politics of distress identifies the implications on self-identity of particular ways of theorising that distress (be it biomedical, social constructionist, feminist etc.) while foregrounding their social contingency. Relocating the performance of distress to the intersection of cultural discourse and the subject as a neo-liberal citizen shifts the consideration of these performances to a broader stage, considers the context within which the conflation of illness and behaviour in biopsychiatry becomes not only possible but desirable, all the while resisting the cultural tendency to seek individualized and totalized explanations for performances of distress.

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[1] Although Szasz is writing during a time of shift from psychodynamic to biomedical psychiatry, Price et. al. (2000) show that this is not the first shift of its kind to happen within the discipline and that the movement between biological to social (ie. Psychodynamic) back to biological then to an amalgam of the biological/social has a long history within the field. For an alternative view of the shifting of priorities in psychiatry, see Lunbeck ( 1994).

[2] Szasz in fact was vociferously critiqued after the publication of The Myth of Mental Illness. In the Preface to the Second Edition, he reveals that calls for his dismissal from his university position because “he did not believe in mental illness” (vii).