The Internet has been increasingly used by governments around the world as a cost-effective way to provide health-related information to various audiences (Barak, 1999; Bennett & Glasgow, 2009; Christensen et al., 2004; Griffiths et al., 2006; Levy & Strombeck, 2002). Whereas the US was an early enthusiast and France a relative latecomer, for almost two decades now, important governmental agencies and mental healthcare providers in both countries have been sharing insights about bipolar disorder online. In so doing, they have been confronted with two major challenges. On the one hand, they need to conform with legislation requiring governmental agencies that have online platforms to make sure that the information they share online is accessible to people with disabilities. On the other hand, they are required to make their views public in a context where many people, including mental health professionals, are critical of psychiatry (Morrison, 2013), and where important struggles take place between the different types of professionals involved. This means that the official character of an institution is no longer a sufficient guarantee that the psychiatric insights it provides are accepted as knowledge, so when sharing information online, official bodies need to make proof of their expertise. Because of these challenges, “science communication represents a crucial activity” (Horst et al., 2017:881) nowadays and the “investigation of the Internet’s applicability as a tool for public mental health interventions is important” (Ybarra & Eaton, 2005:75).

This chapter therefore focuses on the performative techniques that highly authoritative governmental agencies—The National Institute of Mental Health (NIMH) in the US and La Haute Autorité de Santé (HAS) in France—deploy to convincingly perform expertise about bipolar disorder on their online platforms. Coordination plays an important role in the development of expertise, based on the new conceptualization I put forward. Coordination can refer to how different stakeholders come to work together toward a common goal, as we shall see in the next chapter, but it also denotes the fine-tuning activities one and the same stakeholder needs to engage in across different settings, for the knowledge displayed to be authoritative. While such activities are always necessary, online they become all the more important given the multiple presences that one may have, the haphazard way in which the audience might arrive at information, and the manifold ways in which disparate elements can be linked together, thereby acquiring new meaning. This chapter focuses on this dimension of coordination and discusses the activities NIMH and HAS undertook as they had to create and manage relations across different online stages and materials (Drucker, 2011) to convincingly perform expertise about bipolar disorder online. To set the stage, I briefly discuss the context in which the American and the French governments have started to promote the use of the Internet as a cost-effective way to provide mental health-related information.

The Internet in Mental Healthcare in France and the US

As already indicated in the previous chapters, the French mental healthcare system has been undergoing substantial reforms, in order to become more cost-effective. It is against this background that the French authorities started to encourage governmental agencies and health providers to share information online both as a means to educate the general population and to facilitate collaboration between the different types of professionals involved in the provision of mental healthcare. Especially after 2012, the authorities sought to put forward online solutions to reach populations in remote areas, and to prompt people to seek help by providing them with less stigmatizing ways to become informed and to get in touch with medical professionals (eMEN, 2017). Various initiatives and pieces of legislation have facilitated these developments. Important in this sense has been the adoption in 2016 of the law for a “république numérique,” which contains important regulations regarding the online provision of information, greater accessibility, personal privacy, and so on. Furthermore, building upon initiatives such as the “digital hospital program” and “Digital Patient Territories,” on July 4, 2016, the French Minister of Social Affairs and Health presented the first national e-health strategy 2020 (Ministère des Affaires Sociales et de la Santé, 2016; VPH Institute, 2016), where the information, participation, and consultation of users were among the highlights. In the same year, France joined the eMEN, a six-countryFootnote 1 e-mental health project meant to promote the use of innovative digital technologies in the provision of mental healthcare (eMEN, 2017).

Similarly to France, also in the US the authorities started to look for online solutions in the provision of mental healthcare out of financial considerations and because of a dramatic expected decrease in the number of psychiatrists in the near future, due to retirement and low numbers of student applications in relevant fields. It is in this context that the Internet came to be seen as an effective and relatively cheap medium that could be efficiently used (1) to educate people about mental health in an attempt to prevent and to timely diagnose; (2) to facilitate, expedite, and enhance communication between people diagnosed and medical professionals; (3) to enable access to care for people living in remote areas (Farrell & McKinnon, 2003); and (4) to provide treatment in the form of various online therapies (Barak & Grohol, 2011; Ybarra & Eaton, 2005). Like in France, such tendencies were encouraged by the development of various strategies and pieces of legislation. For instance, already in 1996, the Electronic Freedom of Information Act (E-FOIA) Amendments mandated that governmental agencies provide information and make their records available in an electronic format (BIS, 2016; Department of Justice, 2014). Aware of people’s increasing tendencies to look for information online, in May 2012, the White House launched the Digital Government Strategy, which aimed to further encourage agencies to use information and communication technologies (ICTs). It also provided guidance meant to assist them “to improve digital services and use emerging technologies to serve the public as effectively as possible” (OMB Memo 17-06, 2016). As a follow-up on this strategy, the White House released the U.S. Digital Service Playbook in 2014, which offered 13 main recommendations drawn from successful practices developed in the public as well as private sector (ibid.; The U.S. Digital Service, 2018). Despite such encouragement, agencies in both countries also encountered considerable challenges, as I will now discuss.

Technical Challenges: Accessibility Regulations for Online Platforms

While governmental agencies and mental healthcare providers were encouraged through political and legal measures to share their knowledge online, they also had to observe regulations concerning online accessibility. Worried that online information may not reach people with disabilities, in 1998 Section 508 of the Rehabilitation Act of 1973 was amended by the US Congress, requiring all Federal agencies “to make their electronic and information technology (EIT) accessible to people with disabilities” (Section 508.gov, 2017). Importantly, in January 2017, the US Access BoardFootnote 2 ruled in favor of updating the requirements for ICTs mentioned under Section 508 and incorporated by reference the recommendations made by several voluntary consensus standards, such as those issued by the European Commission and the Web Content Accessibility Guidelines (WCAG 2.0). The latter are guidelines developed by the Web Accessibility Initiation (WAI) of the World Wide Web Consortium (W3C, 2017), which is the most important international standards organization for the Internet. This set of guidelines (WCAG 2.0), which became an ISOFootnote 3 standard in 2012, addresses new technologies and focuses not only on the accessibility of people with disabilities but also on that of people using more limiting devices, such as mobile phones rather than computers, laptops, or tablets. Building upon a European Parliament resolution from 2002,Footnote 4 similar legislation was passed in France in 2005. Article 47 of law no. 2005-102 of February 11, 2005 (Loi no. 2005-102), placed public agencies which shared information online under the obligation to render their websites accessible to people with disabilities. The recommendations inscribed in WCAG 2.0 were taken up in the third version of the Référentiel Géneral d’Accessibilité pour les Administrations (RGAA3), which defines the accessibility regulations that governmental agencies and public service providers in France are legally bound to observe. This document was updated in 2015 from RGAA 2.2, to which all French public websites were obliged to comply by May 2012.

According to WCAG 2.0, websites should be perceivable, operable, understandable, and robust. This means that the content put forward should be easy to see and hear and that any non-text content should be accompanied by text options, which can be more easily accessed using braille or speech, among others. At the same time, websites should be designed so that users can easily find their way around them, the information provided on them should be understandable, and the functions they contain should all be accessible using a keyboard. Furthermore, the content provided on websites should not cause seizures, and the compatibility of online platforms with “future user agents, including assistive technologies” should be enhanced (WCAG2.0). Governmental agencies and mental healthcare providers need therefore to make sure that the information they provide on their online platforms is accessible to people with different types of disabilities, to people with different levels of education, and to people whose modest income may mean that they cannot afford a computer, but can only look up such information using cheaper, less developed, or outdated technologies. While such requirements are necessary and laudable, it is important to note that they place significant constraints on these stakeholders regarding the ways in which they can use the Internet and the type of affordances they select for their websites.

Epistemic and Social Challenges: Critique of Psychiatry and Divergent Interests

While the accessibility requirement set upon governmental agencies and mental healthcare providers has led to challenges of a more technical nature, the public character of the Internet has contributed to some epistemic and social difficulties. This second set of challenges refers to the current context in which NIMH and HAS provide insights about bipolar disorder online, where the authority of such bodies is no longer readily accepted and their recommendations are not taken up without critical consideration. According to Rose, (2018:20), “[psychiatry’s] very foundations came under attack from all sides” in the 1960s–1970s, and ever since, the expertise and authority of governmental agencies and mental healthcare providers has been challenged in various ways. Antipsychiatry emerged in that period as a movement which challenged the validity of psychiatric diagnostic and therapeutic practices, considering psychiatry to be an instrument of social oppression and control (Castel, 1976; Rose, 2018). Supporters of the movement further criticized the power imbalance at the heart of all forms of psychiatric treatments and the alienation of medical professionals from their patients. At the same time, many questioned the validity of psychiatric diagnoses, which they saw as arbitrary (McPherson & Armstrong, 2006; Wright & Cummings, 2005) and over-pathologizing (Horwitz & Wakefield, 2007; Scott, 2006), while others denounced the inhumane treatment of people placed in mental hospitals (Gostin, 2008; Morrison, 2013).

The degree to which such critics have opposed and continue to challenge psychiatry has varied as has their identity. Sometimes, criticism has been radical and has included, next to intellectuals, mental health professionals, with psychiatrists such as Szasz arguing that mental illness was a myth, a labeling mechanism through which the social and economic circumstances that dramatically affected people’s lives were occluded from view (Szasz, 1961). Other mental health professionals such as Laing sought for a middle ground, founding residential homes and striving to develop more equal therapeutic approaches (Fussinger, 2011; Roberts & Itten, 2006). Similar variety has characterized the responses of people diagnosed, with some wholeheartedly embracing the medical model, with others arguing against specific medical interventions, such as forced containment and electroconvulsive therapy (ECT), and with yet others, ex-patients or self-entitled “survivors” of the mental health system (especially in the US) rejecting the medical model altogether (McLean, 2000).

Some authors (McLean, 2003; Rissmiller & Rissmiler, 2006) suggest that such antipsychiatric tendencies have been transformed and even integrated within the mental healthcare system they were once so critical of, in part due to psychiatry’s reaction to the criticism received. Thus, psychiatry embraced a biomedical approach in efforts to render itself more scientific, a growing number of medical professionals started to value the insights of their patients, and the rights of the latter came to be codified in patient charters (Hopton, 2006). Furthermore, antipsychiatry supporters are claimed to have morphed in time into members of the broad consumer movement (McLean, 2003; Rissmiller & Rissmiler, 2006), which argues for the inclusion of people diagnosed in decision-making at all levels but which accepts the medical model of mental illness. Such stakeholders are satisfied with the fact that (in principle, at least) people diagnosed have the opportunity to choose the medical professionals they see and also have a say in the treatment they receive. According to proponents of such views, while more radical ex-patients/“survivors” still exist, a new type of consumer has come into being, who no longer shares the feelings of hopelessness of the ex-patients from the 1970s, nor the latter’s strong criticism and suspicion toward mental healthcare professionals.

An overview of books and articles published in the last two decades suggests, however, that such claims about the successful rapprochement between former antipsychiatry supporters and medical institutions underestimate the critical atmosphere which continues to surround psychiatry. Numerous psychiatrists remain critical of their specialty and have come together in various organizations, such as The International Critical Psychiatry Network, to exchange views and to seek to develop alternatives to the current dominant approach. At the same time, they call for drastic reform of the mental healthcare system, arguing that accessibility and quality of care remain importantly dependent on markers of identity, such as class, race, and gender (Hopton, 2006; Metzl, 2009). Another group of critics accuses current psychiatry of medicalization or imperialistic tendencies, as normal aspects of life and behavior, such as mourning, have become pathologized (Lane, 2009). While some commentators consider psychiatry as a political science since its very inception (Rose, 2018), others see an augmentation of its politicization and argue that it puts forward views that have little scientific backing in order to serve particular interests and to uphold certain social values (Wright & Cummings, 2005). Yet others decry the medicalization of mental health conditions in that it focuses solely on medications and neglects social provisions, which are highly necessary for the recovery and social reintegration of people diagnosed (Kinderman, 2014).

Psychiatrists and journalists alike have criticized the close relation between psychiatrists and pharmaceutical companies (Carlat, 2010; Kirsch, 2010; Whitaker, 2010). From this point of view, some deplore the fact that most research on the effectiveness of specific medications is conducted by the pharmaceutical companies themselves, which suggests the results may be biased (Whitaker, 2010). Others downright challenge the effectiveness of medical treatments, arguing, for instance, that there is no significant difference between the effects of antidepressants and those of placebo (Kirsch & Sapirstein, 1998). There are also voices who warn that the promotion of self-determination and empowerment of people diagnosed with mental health conditions may be superficial and represent a political move rather than genuine interest and appreciation for their insights (Bernstein, 2006; Hopton, 2006). A staunch opponent of psychiatry remains the Church of Scientology, which funds the Citizens Commission on Human Rights, the museum Psychiatry: Industry of Death, and which disseminates various materials harshly criticizing the effects of psychotropic drugs as well as the motives and intentions of this profession.

Apart from medical professionals, sociologists, and journalists, critical psychiatric tendencies continue to be put forward by people diagnosed. From this point of view, the Internet has enabled many opponents to come together. According to Whitley (2012:1040), “[t]he Internet has given a means for current and former psychiatric patients, who sometimes refer to themselves as ‘survivors’, to widely disseminate often negative attitudes, beliefs, experiences, and opinions vis-a-vis psychiatry.” An example is The Antipsychiatry Coalition, an organization which aims “to warn you of the harm routinely inflicted on those who receive psychiatric ‘treatment’ and to promote the democratic ideal of liberty for all law-abiding people” at an international level. They challenge the medical understanding of mental health conditions and the scientific bases for the medical treatment prescribed, accusing it to be “quackery,” and organize various actions to raise awareness, such as the Electroshock Protest, which took place on May 16, 2015, in the US. Highly influential in this sense is also Monica Cassani’s blog, Beyond Meds. An ex-patient and mental health professional, Cassani claims that this dual position enables her to share “some interesting and sometimes uncomfortable insights into the mental health system in the United States” (Cassani, 2017). Other ex-patients continue to refuse the medical model of mental illness, arguing instead that their experiences represent different ways of being in the world, and such views are promoted by groups such as the Hearing Voices Network (Hopton, 2006; Romme & Escher, 1993).

The various types of critique enumerated above indicate that there continue to be important differences even among mental health professionals regarding their understanding and approach to mental health. Such differences of opinion are augmented by the various reforms which have been brought to the mental healthcare system in the US and France (Hochmann, 2017), as by limiting insurance coverage and the number of (prospective) specialists, these reforms have led to the marginalization of previously successful professionals, such as psychoanalysts in France (Pignarre, 2006). At the same time, different types of mental healthcare professionals often find themselves in competition for limited resources or have to take over functions and tasks previously fulfilled by other specialists (Desmettre, 2009; Gill et al., 2014). Furthermore, this also seems to prompt some of them to embrace divergent interests and to advocate different approaches. Psychologists often reduce psychiatry to the mere provision of medical treatment and accuse it of neglecting the full person of the person diagnosed. Furthermore, by focusing too much on genetic and neurological factors, psychologists and social therapists argue that important environmental factors are neglected. To the accusation that they merely prescribe psychotropic drugs, psychiatrists reply by pointing to general practitioners as the professionals who often prescribe higher dosages and more medicines than they recommend. As a reaction to extreme biomedicalization, psychoanalysts seem to be making a comeback in the US, even though access to them is heavily restricted by insurance policies (Chessick, 2006; Maness, 2017; O’Sullivan, 2016). In France, the conflict between psychoanalysts and psychiatrists is still fresh (Pignarre, 2006). For instance, a report from 2009 for the Minister of Health and Sports, Roselyne Bachelot, where three approaches to mental health were evaluated, caused a lot of uproar. At a more general level, mental healthcare providers decry the influence of managed care controls and the cost containment policies which have been taken up over the last few decades, and which severely reduce their autonomy and ability to make treatment decisions freely (Scheid, 2000). It is in this context, fraught by different types of challenges, that the online provision of information about bipolar disorder by governmental agencies and mental healthcare providers takes place. Succeeding to perform expertise about bipolar disorder online in such circumstances becomes a rather remarkable feat, which needs to be carefully studied.

Rhetoric and the Performance of Expertise Online

In the field of STS, there is a rich tradition of studies on the construction of scientific knowledge (Bijker et al., 2009; Knorr Cetina, 1999; MacKenzie, 1990; Shapin & Schaffer, 1985/2011), whereby the importance of social, political, and economic factors in processes which for a long time have been claimed to be neutral has been highlighted. In this sense, Felt remarked that “[m]aking knowledge is …never an ‘innocent’ activity; nothing can be regarded as ‘natural’ or ‘simply given’” (Felt, 2017:253). Important to understand the work that goes into the construction of scientific facts is the work of Latour (1987), who shows that “science in the making” is messy, subject to heated debates and controversies, which are often solved by making strategic alliances or by using one’s social capital (Bourdieu, 1975). In what follows, I will discuss how governmental agencies perform expertise about bipolar disorder online, which means that I will not focus on the construction of scientific facts, but will trace, instead, the manners in which they are made available online, their unfolding destiny on these platforms. For this purpose, I adjust the notion of performance put forward by Goffman (1959/1990) building upon insights acquired from its application in the study of scientific authority (Hilgartner, 2000) and the suggestion that this concept may be amenable to the investigation of phenomena involving digital technologies (Hafermalz et al., 2016). Performance thus (re)conceived was combined with insights from Latour on the rhetorical techniques through which scientific facts are constructed and with perspectives from media studies (Drucker, 2011) on the role of various web interface elements on users’ experiences. This innovative approach allowed for various digital objects and technologies to be approached as actors fulfilling different roles and functions in the performance of the two institutions studied here, and focused the analysis on the ways in which seemingly disparate elements—aesthetic, functional, content-related—were combined to put forward specific perspectives on bipolar disorder for particular audiences.

Rhetoric plays an important role in the complex trajectory statements that follow from mere hypotheses or “hunches” to scientific facts (Latour, 1987; Latour & Woolgar, 1979). It also lends itself to the analysis of the relations between the different types of knowledge used in mental healthcare, as positive or negative modalities, which imbue statements with lower or greater degrees of certainty, can convey the dominance of particular ways of understanding while subtly discarding or diminishing others. Such rhetorical techniques are integral part of a performance, but their effects are shaped by other important elements: the team and teammates, who put up the performance, and who can take up different roles, that is, director, actors; the setting, that is the environment where the performance takes place; sign equipment consisting of various props that help foster the impression intended by the performance; and the audience, consisting of those for whom the performance is put up (Goffman, 1990/1959). Whereas the sign equipment and stage Goffman had in mind were of a different material character, the choice of web design elements, the visual cues provided contribute to the production of meaning on online platforms (Drucker, 2013). I therefore suggest that the online technologies these institutions use and the online practices they engage in help foreground particular insights about bipolar disorder while downplaying others. This has implications not only for how this condition is understood by online readers, but also for the credibility and standing of NIMH and HAS.

Important for the success of a performance is the division of the stage into two regions—the front and backstage—which can be accessed by different people and where different behaviors can be taken up. Whereas the frontstage refers to the totality of actions and props that the actors engage with and use in their performance that are visible to the audience, the backstage refers to the elements that one needs to occlude from view in order to guarantee a successful performance, information to which the audience’s access is purposefully impeded. The comparison of the information on bipolar disorder made available online by NIMH and HAS at different moments in time allowed for the identification of novel elements entering the frontstage as well as of insights and perspectives which were downplayed or given up upon. I therefore suggest that in the case of online performances, there may be two types of backstage worth considering: the “conventional” one that Goffman (1959/1990) described, containing interactions and negotiations among the online platform developers, debates among scientists, drafts of the information intended to be made available, and the tools and technologies used for these activities; and a “digital” backstage, containing older versions of the performance and revealing the affordances previously available on these platforms. By comparing them with the current performance, elements which NIMH and HAS may seek to conceal are unearthed. Whereas access to the first type of backstage was not possible for the study described here, the “digital” backstage could be visited by collecting and comparing data from the online platforms at three different moments in time. Data used in this analysis consist therefore of the online pages dedicated to bipolar disorder on the website of NIMH and HAS, and they were collected in 2014, 2015, and 2016.

The success of a performance does not only depend on the talent of the actors and the quality of their parts, but it is also importantly shaped by the stage decorum. Insights from media studies reveal that elements of visual design importantly shape the meaning of the information made available on an online platform. Thus, the quantity of information provided on a particular aspect, where the information is placed on a website, the font size and type, how the information is visually framed by banners and advertisements, a dynamic or static environment, and the type and position of the menu as well as the writing style used guide readers toward particular bits of information, and help them distinguish important insights from less relevant ones (Moshagen & Thielsch, 2010). The use of color is also very important, as color patterns help readers recognize how information is structured and organized; the contrast between foreground and background importantly affects a website’s readability, while the number and kind of colors used and their distribution on the website affect readers’ ability to concentrate and may imbue the information with particular connotations (Cyr & Trevor-Smith, 2004; Flemming, 1998). Next to these elements, the navigability of an online platform and the affordances available to their users importantly shape users’ attitude toward the insights provided. Given the important role they play in the production of meaning and the great variety of ways in which they can be combined online, these elements were also considered when analyzing how NIMH and HAS perform expertise about bipolar disorder online. The data collected and analyzed consist therefore of texts, videos, images, and hyperlinks. In the following, I describe the main performative techniques identified and present images and extracts to illustrate the approaches and online elements that helped put forward particular understandings of bipolar disorder.

Performative Techniques and Online Expertise About Bipolar Disorder

NIMH and the Quest for the Redefinition of Bipolar Disorder

NIMH is the main agency of the American government responsible for biomedical and health-related research. It is the largest research organization in the world focusing on mental health. With a budget of about $1.5 billion, NIMH conducts its own research, but also largely determines the national research agenda by providing grants to other institutes and organizations throughout the US. In what may be seen as an attempt to counter anti-psychiatric tendencies, since the 1980s, NIMH has also started to pay more attention to the perspectives and insights of people diagnosed with mental health conditions. For instance, it has funded self-help agencies managed by former patients or self-titled “consumers,” which nowadays together constitute The Center for Mental Health Services. At the same time, NIMH has launched two research centers with the task to study the activity of self-help groups and the (therapeutic) effectiveness of such initiatives among people diagnosed with severe mental health conditions (Borkman, 1997). Important to understand the highly influential position NIMH occupies is the distinction between being “in authority” and being “an authority” put forward by Jongen (2017). Being in authority refers to the mandate certain governmental bodies receive to develop rules and regulations and even to make decisions for others. Being an authority is linked to the epistemic authority of certain institutions or people, and highlights the relation between the bearers of such authority and those who grant it. NIMH is therefore both in authority, by actively shaping the activities of numerous institutions and self-help groups, and an authority because of the prestige it enjoys. Furthermore, it is endowed with sufficient resources to shape its online presence as its representatives best see it fit.

By analyzing the online materials described above, I found that NIMH performed expertise about bipolar disorder online as stable and authoritative and achieved this by prioritizing on its platform understandings and approaches that could lend themselves more easily to observable and quantifiable investigations. Important in this sense was the understanding of bipolar disorder that NIMH put forward. Whereas this condition is generally conceived as a “mood disorder” and the role of the brain in its onset and development is still debated, NIMH referred to the brain being its main causal factor as an unproblematic fact. According to the institute (2014, 2015, 2016), “[b]ipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.”

This seemingly stable and unproblematic definition of bipolar disorder was maintained through the deployment of three sets of omissions and by operating an important modification to a related concept. Thus, while bipolar disorder was defined rather unproblematically as a brain condition throughout the time period studied, the definition of a mood episode was broadened to include next to emotional states (2014) also different levels of energy and types of behavior (2016). Thus, NIMH modified the weight ascribed to the various markers of this condition and, in so doing, put forward a more complex image of bipolar disorder. This challenges the views of commentators who have expressed concern that the rise of “the brain” in mental health research would oversimplify how mental health conditions are understood and approached. The fact that moods were brought by NMH on a par with other aspects, such as one’s ability to engage in various acts, does foreground, however, more quantifiable approaches to how bipolar disorder is diagnosed, as medical professionals need to assess a person’s behaviors along a growing number of dimensions and at a more granular level. Thus, whereas the definition of bipolar disorder seemingly stayed the same, the means by which this condition can be known were transformed. Bipolar disorder thus gradually became a condition which can be more easily recognized and monitored from the outside, even in the absence of highly deviant behaviors, and, importantly given the various digital and AI-based technologies discussed in the first chapter, along quantifiable markers.

Despite this important change, NIMH succeeded to perform expertise about bipolar disorder as stable and unproblematic by operating three sets of omissions: (1) keeping backstage insights about its changing perspective on bipolar disorder; (2) not providing information on how scientific, social, and technological factors inform this perspective; and (3) not engaging with its societal significance. These omissions were successfully achieved through a shrewd combination of rhetoric and the use of specific sign equipment, that is, of specific digital affordances. Thus, the impression of epistemic stability was supported by NIMH’s decision to dress its main character in the modest costume of digital text, which gives the illusion of permanence and immutability. No further details were given regarding the designer(s) of this costume, when it was produced and how. Building upon Latour’s (1987) insights, this choice may have been informed by NIMH’s desire to highlight the scientific character of the information it provided, by rendering it “devoid of any trace of ownership, construction, time and place” (Latour, 1987:23). Yet, a look into the backstage of NIMH’s platform, that is, at records of the information previously available on its main page dedicated to bipolar disorder, revealed that in 2014 the institute was more optimistic about the genetic causes of this condition, both in terms of content and the amount of space dedicated to them:

Bipolar disorder tends to run in families. Some research has suggested that people with certain genes are more likely to develop bipolar disorder than others. Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness. (…) But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder, despite the fact that identical twins share all of the same genes. (NIMH, 2014)

Whereas in 2014, NIMH did not hesitate to suggest bipolar disorder may be a condition occurring in families, by 2016 the language it used about genetic causes had become more tentative:

Some research suggests that people with certain genes are more likely to develop bipolar disorder than others. But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that even if one twin develops bipolar disorder, the other twin does not always develop the disorder, despite the fact that identical twins share all of the same genes. (NIMH, 2016)

The 2016 text may be seen as an attempt to preempt alarm among the relatives of people diagnosed with bipolar disorder, and its brevity suggests that NIMH may have assumed this information not to be particularly interesting for its audience. The use of indefinite adverbs and adjectives, such as “some” and “certain,” and the omission of any references does not encourage the audience to look further into these matters. The audience is therefore expected to believe these statements simply because they have been uttered by a stakeholder already recognized as an authority. While it makes sense to retain on the website the most up-to-date insights about bipolar disorder, this comparison highlights the performative effects of the “presentism” that digital platforms afford, particularly when the focus can be maintained on the frontstage. Thus, the possibility to avoid any discussion of the processes and evaluations whereby content is modified helped promote an image of NIMH’s expertise about bipolar disorder as stable and unquestionable.

This impression of stability was also reinforced by NIMH’s omitting of any insights about the factors that influence its orientation as to the most fruitful areas of research into the causes of bipolar disorder. Whereas describing bipolar disorder as a brain condition favors a neuroscientific approach to it, NIMH did not share any details regarding the type and amount of scientific evidence which led it to support this conceptualization. Nor did it indicate to what extent advances in neuroimaging technologies and techniques prompted it to consider that “the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders” (NIMH, 2017). In so doing, NIMH occluded from the audience’s view the role factors such as the dynamic assessments of scientific feasibility, the changing popularity and influence of specific scientific fields, charismatic scientists, available technologies, financial costs, and administrative and organizational obstacles play in such processes of knowledge production.

NIMH further omitted to publicly consider the societal significance of its conceptualization, to ponder on how the understanding of bipolar disorder as a “brain condition” that can be measured and monitored along numerous parameters may impact on the types of mental health professionals involved and on the work they do, on the experiences of people diagnosed with this condition, and on the social provisions they are entitled to. Through such omissions, the institute positioned this knowledge as natural, obvious, unproblematic. In so doing, I argue that NIMH performed yet another type of omission, as it appeared rather oblivious to the distrust some people experience in regard to psychiatry and governmental institutions, discussed in the earlier sections of this chapter. All these are issues that NIMH kept backstage, successfully occluding them from view in its performance.

The Role of Sign Equipment in NIMH’s Performance on Bipolar Disorder

As already mentioned in the previous chapter, the type of platform a particular stakeholder chooses depends on its status, on the resources it has available, and on its goals. From a financial and technical point of view, non-interactive online platforms are less challenging, as they represent variations upon options which have been available since the early days of the Internet. Considering the relatively simple technologies and programming functions required for their development as well as their limited interactive potential, non-interactive online platforms may be seen as rather conservative options in the current digital environment. They are hardly ideal for governmental agencies which aim to educate their audiences and encourage them to use (certified) online resources. Furthermore, in a context where such official bodies find themselves under the obligation to have an online presence, opting for a non-interactive online platform does not help them position themselves as open and transparent. Nevertheless, such platforms continue to be the preferred choice for many official institutions, which seem to be more interested in making information available to the public rather than also acquiring direct insights into the public’s views and experiences.

NIMH opted for a non-interactive online platform, and its considerable budget suggests that this choice was motivated by other reasons than financial concerns. If we look at the information NIMH provided on its online platform as a performance, then the visual, structural, and functional aspects of the site (see Fig. 3.1) represent important elements of the sign equipment used, which are meant to contribute to a persuasive performance. The ways in which information is structured and organized on the platform together with the choices that were made regarding webpage and navigation design are relevant, because they help orient the audience toward particular understandings (Djonov, 2007).

Fig. 3.1
A screengrab of the bipolar disorder page represents descriptions for What is bipolar disorder? causes, and clinical trials. The left pane has a box with subheadings for, what is bipolar disorder? The right pane has the symbols of the social media and links for the related topics.

Images of the upper and lower parts of NIMH’s website (2016)

Full size image

As can be seen in Fig. 3.1,Footnote 5 NIMH opted for a rather minimalist visual design for its online platform. Blue and gray were the main colors used and they fulfilled important functions, as they highlighted specific rubrics or content. The choice of colors is in line with the WCAG 2.0 recommendations, which mention that a good distinction between foreground and background enhances readability. By choosing to give its performance in a minimalist setting, I argue that NIMH revealed its awareness of the highly authoritative position it occupies, of the fact that it does not need to use any apparent embellishments to draw crowds in for its performance. Furthermore, this apparent simplicity may fulfill another important rhetoric function, as it might signal to the audience that the scope of the performance is to reveal the truth about bipolar disorder without any artifice and in an unbiased fashion. The sober colors used on the platform together with the basic affordances can thus be interpreted as a visual enactment of scientific rigor and authority. At the same time, they also steer the audience to focus on the content made available.

While the visual design of the site is how NIMH chose to decorate the stage for its performance, I consider the platform’s rubrics to be stage props, which contributed to the institution’s self-presentation and revealed the targeted audience and the type of relation NIMH envisaged with it. Thus, the information it made available about bipolar disorder was placed under the more general rubric entitled “Health & Education,” which indicated that the insights provided were meant for the general population and not for mental healthcare professionals. In so doing, NIMH seemed to be positively responding to the various measures taken by US authorities to encourage the use of the Internet for mental health-related education. The horizontal rubrics at the top—mental health information; statistics; consumer health publications; help for mental illnesses; clinical trials—brought together different types of knowledge and positioned NIMH as an institution devoted to furthering scientific knowledge while being appreciative of the insights shared by people diagnosed with mental health conditions. At the same time, these rubrics helped remind the audience that the institute is dedicated not only to research but also to improving the lives of people diagnosed.

Whereas the rubrics at the top of the website served self-presentation purposes and focused on the institute’s missions and prerogatives, those in the lower part of the page revealed how it used its online platform. Thus, they contained brief clarifications regarding NIMH’s position on FOIA, accessibility, privacy, its policies, and the ways in which it could be contacted. Regarding accessibility, NIMH assured its readers that it “is making every effort to ensure that the information available on our website is accessible to all. To meet this commitment, we have designed our site to comply with Section 508 of the Rehabilitation Act.” Nevertheless, NIMH reserved for itself the right to decide how to fulfill this commitment. Thus, while the static character of its website facilitated its accessibility, it did not provide text alternatives for some of the videos put up. From this point of view, it would appear that NIMH used the accessibility guidelines in ways which allowed it to opt for the platform design and online affordances that it preferred.

Important insights regarding the goals of the performance NIMH put up and about its intended audience were provided under the rubric “Policies,” where it became apparent that the institute mainly focused on the general public rather than medical professionals. In so doing, NIMH was wary not to jeopardize or diminish the authority and prerogatives of medical professionals, as it

does not intend to provide specific medical advice on our Web sites, but rather to help visitors better understand mental health and disorders. NIMH will not provide specific medical advice and urges you to consult with a qualified mental health or health care provider for diagnosis and for answers to your personal questions.

In line with the institute’s penchant for conservative choices regarding its online platform, the role of the audience to the performance was limited. It could not engage in processes of knowledge production and evaluation through direct reactions, nor could it publicly challenge in this online space the vision of bipolar disorder NIMH put up. Furthermore, the peripheral position ascribed to the option “Contact Us” suggested that dealing with public inquiries was not a function NIMH prioritized. While localized engagement or resistance was this way discouraged, the audience was allowed, however, to play an active role in ensuring the circulation of NIMH’s insights by printing, e-mailing, or sharing them on social media. Even though these online affordances are common elements on most websites nowadays, I argue that they fulfilled a performative function nonetheless, as they suggested that the knowledge NIMH made available was relevant and interesting enough for people to want to keep it or to inform others about.

The simplicity and clarity of the platform was aligned with the ways in which the part of the main actor was structured and worded. Thus, NIMH’s perspective on bipolar disorder was organized along the following rubrics: definition; signs and symptoms; risk factors; treatments and therapies; join a study; and learn more. As these rubrics already suggest, the information provided contributed to a performance whereby bipolar disorder was presented as a complex but manageable condition. A hopeful, optimistic tone was maintained by mentioning ongoing studies meant to shed further light on its causes and reveal fruitful new forms of treatment. The vertically organized rubrics on the right played an important role in supporting this perspective, as they helped convey a dynamic, productive view on bipolar disorder research, with new insights being frequently put forward and new studies developed for people to join. The mobile character of these videos and hyperlinks had a double function, as they helped highlight the stability and importance of the main actor, and also reminded the audience of NIMH’s prerogative and dedication to tackle the complexity of bipolar disorder. Thus, whereas the institute was rather conservative in how it performed expertise, it did use the latest approaches to online technologies when they served its purposes.

Goffman’s dramaturgical approach helped highlight some specific ways in which the (visual) design of NIMH’s online platform and the online affordances available on it participated in shaping the meaning of bipolar disorder and the institute’s public image. Sharing information online requires important coordination work between distinct elements and the choice of these elements is often indicative of the type of audience targeted and how it is expected to engage with the information provided, as the discussion of HAS’ performative techniques will indicate.

HAS’ Performative Techniques to Redefine Bipolar Disorder

HAS is an independent public institution with a scientific character, created in 2004. Its board consists of eight members appointed for six years (with the possibility of renewal every three years) by the President of France (two members can be proposed by the President, two by the President of the Senate, two by the President of the National Assembly, and two by the President of the Economic, Social, and Environmental Council (CESE)). HAS fulfills three main functions: (i) to evaluate from a medical and economic point of view health products, technologies, and practices in view of their admission for reimbursement (a French version of Health Technology Assessment); (ii) to provide recommendations on healthcare practices and public health; to create guide books on treatment for patients and medical professionals; to develop medico-economic studies; to advise public institutions in their decisions regarding public health, and to define the trajectory of personalized care to which one is entitled; and (iii) to certify healthcare establishments and to provide accreditations for medical professionals. Very important for this study is that HAS also certifies health-related online platforms. Its current annual budget is €60 million, and its revenue comes from taxes on promotional spending by drug companies, National Health Insurance, state funding, HONcode accreditation fees, payment for assessing applications for inclusion on reimbursement lists, and so on.

Based on the online materials examined, I found that HAS performed expertise about bipolar disorder online so as to assist in the reform of the French mental healthcare system. As mentioned in the previous chapter, France struggles due to an insufficient number of psychiatrists, and one of the solutions that have been put forward in recent years has been to more extensively involve other medical professionals in the provision of mental healthcare. General practitioners (GPs) are among those meant to take over some of the responsibilities previously bestowed upon psychiatrists. To better prepare the GPs, HAS provided them with important and varied insights and thereby made ample use of the fact that the architecture of online platforms rendered the existence of multiple simultaneous frontstages possible. The agency thus developed three frontstages where it put up different but related performances about bipolar disorder: a memo card with recommended practices for the diagnostic and management of bipolar disorder (2015); a press communication in HAS’ online magazine (2015); and a guide for bipolar disorder as a chronic condition (2016) (Fig. 3.3). In so doing, HAS indicated its awareness that it was in authority to provide its intended audience of medical professionals with guidelines regarding various tasks and competencies, ranging from the correct diagnosis of bipolar disorder, to familiarity with the new distribution of duties and responsibilities between GPs, psychiatrists, other mental healthcare professionals, and patients (see Figs. 3.2 and 3.3), to indications of the types of therapeutic interventions that were officially reimbursed (see Fig. 3.3). This way, HAS performed expertise about bipolar disorder through the provision of recommendations regarding diagnostic and therapeutic practices and a clear distribution of responsibilities. In what follows I will zoom into its performance of expertise through the memo card and will show that unlike NIMH, which made efforts to steer away from dramatic overtones and to maintain the impression of stability in regard to its perspective on bipolar disorder, HAS actively engaged in the reconceptualization of this condition by operating several plot twists.

Fig. 3.2
A screenshot of the H A S website with the evaluation and recommendation tab selected. There are three panels with the text written in a foreign language.

Images of the upper and lower parts of HAS’ online page on the diagnostic and treatment of bipolar disorder

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Fig. 3.3
A screenshot of the H A S website with the evaluation and recommendation tab selected and links to two documents have been provided. The website contains text in a foreign language.

Images of the upper and lower parts of HAS’ online page dedicated to bipolar disorder as a chronic condition

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This performance took place on a stage where three main actors shared information (see Fig. 3.2): (1) a storyteller that informed the public about the aims with which HAS had developed the memo card and the audience it addressed; (2) a main character, the memo card, which consisted of an overview of practices meant to help doctors diagnose and treat bipolar disorder efficiently and effectively; and (3) another main character, the report on the elaboration of the memo card, which effectively transported the audience backstage, revealing the processes and negotiations through which the memo card came into being. Whereas NIMH understood bipolar disorder as a brain condition, HAS focused on its “evolution” in time and reconstructed bipolar disorder as a largely developmental or degenerative condition. The agency stated, for instance, that the periods of remission between episodes would get shorter in time, especially if bipolar disorder was not treated, whereas the number of depressive episodes would become more frequent and last longer. HAS thus emphasized the importance of correctly diagnosing this condition as early as possible, it signaled its severity, and it highlighted the relevance of treatment. Since it also heightened the pressure for medical professionals to correctly identify bipolar disorder, such a redefinition functioned as a performative technique through which HAS sought to achieve one of its stated goals, namely the reduction of diagnostic delay (HAS, 2015a).

To this aim, HAS further operated another and, arguably, most dramatic twist in its performance of expertise about bipolar disorder, as it depicted suicidal attempts as symptoms of this condition and described bipolar disorder as “a highly suicidogenic pathology” (2016). Since statistics confer an aura of objectivity and credibility to the information provided, making it seem more factual and more urgent (Potter, 1996), the main actor called upon them, to legitimate this understanding of bipolar disorder. Thus, it warned the audience that one out of two people diagnosed with this condition would make at least one suicide attempt and that at least one out of ten untreated patients would commit suicide, which accounted for 15% of the population of people diagnosed with bipolar disorder. The performance HAS put up on this frontstage was aligned with its institutional role, as through it, the agency guided medical professionals in the assessment of the suicide risk their patients posed. It did so by developing indicators specific to bipolar disorder: an early onset of the condition; the presence of mixed characteristics; rapid cycles; the presence of psychotic symptoms; alcohol addiction; and addiction to illicit substances or to other psychoactive substances. Furthermore, HAS engaged in the construction of new categories, as it put forward a specific assessment of a suicidal crisis—low, medium, high—and positioned social isolation as an indicator of medium or high level. In so doing, the agency framed the ability to assess the risk of suicide as one of the competencies that medical professionals involved in the management of this condition needed to master. The attention to the new skills and abilities required marks an important difference between HAS and NIMH, as the latter omitted to include in its performance of expertise considerations about the ways in which changes in its understanding and approach to bipolar disorder would shape the work of medical professionals.

The presence of the report on the elaboration of the memo card as another main actor of this frontstage illustrates HAS’ commitment to transparency and public accountability. This document indicated the credentials of the team of experts involved, testified to the depth and breadth of the literature reviewed, and revealed the numerous actors that were consulted before the final product—the memo card—was publicly made available: different types of medical professionals, several patient organizations, non-governmental organizations, etc. It thus rendered transparent the processes by which the memo card came into being and transported the audience onto the backstage. Whereas such information was absent from the online platform of NIMH, possibly in order to avoid any liability and potential causes for litigation, the audience of HAS had thus the opportunity to understand the tremendous scientific and diplomatic effort involved in such an undertaking, and was invited to appreciate this institution’s inclusive character. By placing on the frontstage a document which one generally expects to find relegated to the backstage, HAS sought to legitimate and heighten the acceptability and authority of the memo card, while also positioning itself as a reliable, transparent, and democratic institution.

The Role of Sign Equipment in HAS’ Performance of Expertise

The structure of the performance HAS put up and its choice of stage equipment were by no means accidental, but were aligned with the intended audience and educational purposes. HAS’ performance was organized as a series of monologues, with each individual character taking its turn to play its part. The main characters were dressed in the simple and conservative outfit of portable document format (pdf) files, whereas some of the side actors were wrapped in the equally conservative suit of digital text. These choices enabled the audience to focus upon what each character had to say without any interruptions, contradictions, or divagations. At the same time, by wearing such hard and impenetrable costumes, each part the characters had to say, every insight and practical advice about bipolar disorder that they provided acquired stability and authority, which befit scientific facts. Furthermore, pdf files allow for relevant information to be highlighted and easily identified, they enable users to add their own thoughts and ideas in the form of comments and notes, and they can be accessed from a variety of devices. Thus, not only did such attires allow HAS to fulfill the WCAG 2.0 accessibility recommendations, but they could also be more readily consumed by careful and goal-oriented readers, such as treating doctors, who need to act quickly and who require stability and coherence in their practices.

The doctors’ projected increase in workload and the need for efficiency may have prompted HAS to endow some of its main actors with an additional costume, the audio file. The audience could thus have a say in how these actors brought forward their monologues, as it could listen, read, or opt for a combination of the two. Furthermore, the audience could also take in the performance with the additional help of a “reading ruler,” which allowed it to read in a more focused way or to keep up with the pace of the speaker (Fig. 3.4). This way, HAS made it possible for treating doctors to choose a format which was better aligned with their personal studying or memorizing techniques, as some would focus better using visual means and others audio props, while yet others a combination thereof. Furthermore, while the typed text required the audience to focus mainly upon it, the audio format enabled it to also listen to HAS’ advice when engaged in other activities.

Fig. 3.4
A screengrab of a document on page 4 opened in the docReader with several options on the top. The text is written in a foreign language.

Image of the affordances—audio and reading ruler—of a .pdf file provided by HAS

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As the distribution of roles and the choice of decorum indicate, HAS staged its performance on bipolar disorder as a rather idyllic world, where the best results could be achieved when treating doctors corroborate their treatment decisions with legal provisions regarding the insurance and reimbursement of medical care and when they provide their patients with documentation meant “to support the dialogue” between them. Given the currently fraught relations between different types of mental health professionals in France, this approach may have been taken in order to provide an example for its medical audiences to follow, as an attempt to achieve not only informational but also behavioral changes. These considerations may have therefore informed HAS’ choice of costume for its characters as well as the way in which it organized the reverberations of several plot twists across different regions of its three stages.

Discussion

This chapter discussed the performative techniques through which two highly influential institutions performed expertise about bipolar disorder online, in a context in which official bodies are required to make their insights available via the Internet, but face important challenges to their authority, and need to respect specific technical provisions. It showed that NIMH and HAS performed expertise about bipolar disorder in different ways, as NIMH used various strategies to depict its perspective on this condition as stable and precise, whereas HAS actively and transparently engaged in its redefinition to assist in the reform of the French mental healthcare. The type of information shared depended on the intended audience, and the visual design and most of the affordances available on the online platforms of these institutions helped the audience better find their way while reiterating the authoritative position of NIMH and HAS. As we have seen, these institutions were not enthusiastic users of the Internet, exploring its full potential and experimenting with the latest online technologies. Instead, they opted for non-interactive online platforms, reminiscent of the Web 1.0 era, with static content and limited interactivity. Combined with various rhetorical strategies, this conservative choice enabled, however, these institutions to put forward their knowledge on bipolar disorder as reliable and authoritative. This means that the accessibility commitment need not only pose difficulties or bring additional challenges to public institutions. Instead, it might allow such bodies to engage with preferred digital technologies to put forward a desired public image and to bestow their insights in ways that highlight their legitimacy.

Even though both NIMH and HAS used largely similar performative techniques, they approached bipolar disorder in different ways, which seems to confirm yet again that national characteristics and priorities specific to any given healthcare system shape the content public bodies share online. For instance, the higher suicide rate in France (14.3%) as compared to the US (13.1%) (OECD, 2015) may be the reason why HAS chose to perform expertise about bipolar disorder by developing categories of suicide risk and by defining this condition as highly suicidogenic. Similarly, NIMH’s definition of bipolar disorder as a neurological condition is understandable in the American context, where the biomedical model remains dominant and where Congress has been increasingly approving the allocation of funds in areas of research which can provide hard evidence and lead to findings that are easier to render profitable. Nonetheless, while politics play an important role in the functioning and orientation of both agencies, they both successfully managed to relegate it to the backstage, presenting an image of governmental bodies moved by the sole purpose of furthering science and improving the treatment and provision of care to people diagnosed with bipolar disorder.

The analysis discussed here was colored by a specific normative perspective, which sees non-interactive online platforms as rather conservative, whereas interactive online platforms are perceived as more dynamic and amenable to varied purposes. Choosing for an interactive online platform can be problematic for official institutions, because of the inherently generative character of such platforms, where users can engage with the content made available in ways that may lead to interpretations and evaluations of varying quality, and may put forward suggestions that may be detrimental to others. It is regrettable, however, that neither NIMH nor HAS tried to reach a balance between control over the platform and more distributed forms of agency, where users would have had some possibility to contribute, if not to the production, then, at least, to the evaluation of the insights these institutions shared. The need to educate people of different socioeconomic levels and to render insights available to those with disabilities is not a sufficient explanation for their choice of platform type, since online technologies with more open and flexible affordances exist, which can be accessed also from affordable devices. From this point of view, NIMH and HAS’ approach is in stark contrast to initiatives developed in recent years in personalized health and e-health (Sardi et al., 2017), where diverse, interactive, gamified elements are integrated to digital technologies and applications to encourage users to engage with the information provided in specific ways. While important reservations exist in regard to such approaches (Lupton, 2020; Prainsack, 2017; Sharon, 2016; Swierstra, 2016; van Dijk et al., 2018) and they need to be carefully considered on a case-by-case basis, the use of interactive online platforms endowed with a diverse array of affordances may help people acquire a better and longer-lasting understanding of complex issues and may further public engagement.

Both NIMH and HAS took up the incentive to share knowledge about bipolar disorder online, but they did so in ways which suggest that they were either oblivious or unwilling to substantially engage with the fact that their authority is questionable and questioned and that they need to convince as experts if they want to succeed in educating their audience. The analysis indicated that whereas HAS had made some efforts toward acknowledging its public accountability, NIMH largely continued to issue pronouncements in a technocratic fashion. While this approach might be a defense mechanism, a way to steer off the public critical climate, it renders these agencies less effective in the convincing provision of insights. Through such practices, they also do not live up to the image they seek to perform online as supporters of public engagement. Whereas this chapter has described how influential governmental agencies performed expertise about bipolar disorder online, in the next chapter I will argue that a particular type of interactive online platform—blogs—allows people diagnosed with bipolar disorder to engage in more substantial ways in processes of knowledge production and evaluation of treatment.