A Discourse Analysis of Self-management for Bipolar Disorder

Abstract

In line with a movement across all areas of health concerned with chronic illness, self-management practices have become an important part of what it means to provide contemporary mental health care to people with the psychiatric diagnosis of bipolar disorder. In mental health settings it is a taken-for-granted practice. The aim of this thesis is to use Foucauldian Discourse Analysis to explore how the discursive practices of self-management for bipolar disorder produce particular forms of subjectivity for those understood to have the condition and the implications of this for processes of self-formation. In order to consider how discourse is used to both govern others and govern the self, two sources of text are used for analysis. The first source is the Psychoeducation Manual for Bipolar Disorder (Colom & Vieta, 2006) which details how mental health professionals can teach people with bipolar disorder about their condition in order that they might better manage themselves. The questions guiding the analysis of this text as how discourse constructs bipolar as an object, what subject positions it makes available and what relationship people are expected to have with the object named as bipolar disorder. The second source of text are the transcripts of semi-structured interviews completed with 25 people with bipolar disorder as part of their entry to a clinical trial of psychotherapy and medication management as a means to reduce rates of acute psychiatric assessment and hospitalization. Analysis of these texts is concerned with how discourse is used to govern the self and is developed in a two stage process. The analysis is guided firstly by questions that ask how bipolar disorder is constructed, how is self-management constructed as an object, how is life with bipolar disorder constructed and what discourses are drawn on the process. The second stage of analysis of these texts focuses on the subject positions being made available in self-management discourse. This analysis finds that as an object, bipolar disorder is constructed as both an illness of the brain and an object the produces an unreliable mind such that it is an object that is separate from a person’s sense of self while also being an object that interferes with the mind’s capacity to know itself. This results in persistent tensions to be negotiated within self-management practices such that self-management discourse produces subject positions characterised by dividing practices and contradiction. The discourses of medicine and psychology can be seen to act to tightly regulate how bipolar disorder can be understood which results in all aspects of a person’s self being shaped by the condition they are understood have. These discourses have become the only way a person can legitimately construct a sense of themselves and through the workings of pastoral styles of power relationships psychological discourse can be seen to be used ultimately in the service of medical discourse. With self-management discourse seen as operating on the basis of division and contradiction, this thesis proposes that the nature of the problem in the self-management of bipolar disorder is not the disorder or the person it is understood to inhabit but rather the norms of the self on which contemporary Western society bases its understanding of what it means to be a normal subject. The thesis concludes firstly with two alternate constructions of selfhood; the self as formed through connection and the self as formed through the management of the abject and then with a proposal for an alternate approach to psychoeducation as a particular strategy of self-management discourse for bipolar disorder. The significance of this thesis lies in its use of a Foucauldian methodology to question the assumptions of beneficence understood to drive the promulgation of self-management practices in health care. Its resulting re-evaluation of the nature of the self in the discursive practices of self-management for bipolar disorder and its proposal for an alternate approach to psychoeducation is put forward as a contribution to the project of a contemporary critical psychiatry.