Online Expert Mediators: Expanding Interactional Expertise

Abstract

This chapter shows that the Internet does not always favor the powerful, but this still does not mean that it is democratizing. It traces the online activities of two bloggers diagnosed with bipolar disorder using the concept of interactional expertise (Collins & Evans, 2002). I argue that by combining medical knowledge with their situated experiences and the affordances of blogs, these bloggers have become a new type of stakeholder, “online expert mediators.” The notion of interactional expertise is extended by illustrating the relevance of the medium through which interactional expertise is performed and by showing that it has a substantial bi-directional character.

A modified version of this chapter will be published in the special issue “Expertise and Its Tensions” in Science and Technology Studies. Whereas the chapter focuses on two bloggers—Natasha Tracy and Julie A. Fast—in the article, the online and offline activities of another blogger—Charlotte Walker—are also discussed.

Blogs are interesting. They show that humans want to communicate. They show that we want to share our stories. They also became money making opportunities and vanity projects that sometimes make me question my own motives. I am VERY careful about what I share. I am personal without over-sharing. I’m careful of my brand. I protect it every day. I know what I write and I know the effect it has on my audience. (Fast, May 8, 2017, e-mail interview)

This is how Julie A. Fast, one of the best-known bloggers on bipolar disorder and a person who, based on her own admission, has helped shape this genre, describes this type of interactive online platform and her engagement with it. This quote is impressive in its honesty and it also highlights specific opportunities the Internet has contributed to as well as the need for a particular type of expertise to be able to take advantage of them. This chapter is dedicated to the study of interactional expertise, focusing on the activities of two highly successful bloggers diagnosed with bipolar disorder. Whereas in the previous chapter one of them figured in her function of platform owner, shaping the conditions of possibility for other people diagnosed with bipolar disorder to contribute online, here their personal substantial engagement in the development of new knowledge will be focused on. In so doing, the relevance of the multiple and shifting positions that stakeholders can occupy in relation to the development of expertise, which is foregrounded in the new conceptualization thereof that I put forward, will be highlighted.

Relations between important stakeholders in the field of mental health have been significantly transformed by the Internet (Barak & Grohol, 2011). This medium has affected the identity and the type of interactions between knowledge producers and users (Wyatt et al., 2013), contributing to the diversification of sources of medical knowledge away from clinical environments (Nettleton, 2004), closer to the everyday settings of people diagnosed (Lucivero & Prainsack, 2015), and leading to the re-appreciation of other types of knowledge (Schaffer et al., 2008). Such changes have taken place in a context where pronounced neoliberal tendencies have introduced a market logic in the provision of healthcare and have encouraged individuals to assume responsibility for their health (Novas, 2006; Rose, 2007). Web 2.0 technologies enable users not only to consume information but also to engage in its production (Lupton, 2014). Thus, the current dominant imperatives to stay or become healthy by seeking and sharing health-related information have contributed to the development of a space where new forms of agency can develop (Kivits, 2013). Whereas the previous chapter has shown how people can perform lay expertise and collectively contribute new insights about bipolar disorder, the focus shifts here to the new entrepreneurial subjectivities (Tutton & Prainsack, 2011) that these technologies have contributed to. By studying the activities of two bloggers using Collins and Evans’ (2002) concept of interactional expertise, I show that through their skillful use of the Internet, some individual patients have become highly influential, and argue that this medium has thus helped facilitate the emergence of a new type of stakeholder—the online expert mediator. In so doing, I expand the notion of interactional expertise by arguing that it has more of a bi-directional nature than Collins and Evans (2002) and Collins et al. (2017) assume and that it is important to consider the effects of the medium through which it is performed. But first, let us consider how the role of patients in mental health has changed over the last few decades, focusing on the Internet’s influence in these transformations.

Greater Mental Health Patient Engagement and the Internet

As many medical sociologists have indicated, since the last few decades of the twentieth century patient engagement has been promoted in different areas and for different goals (Barello et al., 2014; Turner, 1995), through top-down processes (Godfrey et al., 2003; Hogg, 2009) or as a result of grassroots activities (Barbot & Dodier, 2002; Kushner, 2004; Landzelius, 2006; Novas, 2006; Rabeharisoa et al., 2013; Taussig et al., 2003). The meaning and consequences of patient engagement vary (Hickey & Kipping, 1998; Rowland et al., 2017), yet, as the findings in the previous chapter show, people diagnosed have also come to grasp the conditions of complexity and uncertainty under which medical professionals operate, leading to a growing awareness of the limits of medical expertise. These realizations have had a profound resonance in mental health, where the authority of medical professionals has been challenged since the late 1960s (Pickersgill, 2012), in manners which were discussed in more detail in the introductory chapter. Combined with official restructuring initiatives and considerable openness among people diagnosed toward new approaches and types of knowledge, such challenges have contributed to the proliferation and diversification of mental health professionals (Brown, 1988; Grob, 2005). The relations between existing stakeholders have thus been modified, and the role of patients has changed from passive recipients of care (Barnes & Shardlow, 1997) to consumers who feel entitled to choose the type of care they receive (McLean, 2000). While some patients consider themselves survivors and actively militate against medical conceptualizations and interventions (Crossley & Crossley, 2001; Speed, 2006; Whitley, 2012), many others have engaged in processes of knowledge production (Gillard et al., 2012; Kemp, 2010), evaluation (Director, 2005), and implementation (Davidson, 2005), thereby acquiring a greater role in mental health.

People diagnosed have used the Internet for different types of epistemic engagements. Some patients have used the knowledge thus acquired to question and/or challenge the expertise of medical professionals in several ways (Fox et al., 2005; Gowen et al., 2012; Mulveen & Hepworth, 2006; Orsini & Smith, 2010). Others have engaged in various scientific activities, ranging from monitoring themselves using self-tracking devices and sharing their data with others to using collaborative platforms, such as PatientsLikeMe, to test medical hypotheses (Kallinikos & Tempini, 2014). Through their use of the Internet, such “citizen scientists” or “health hackers” have gone beyond the mere provision and exchange of medically interesting information, connecting with other people with the same diagnosis to “conduct clinical trials on their own diseases” (Bottles, 2013:88), thereby enacting particular values and ideals of patienthood (Sharon, 2017). Such online opportunities have been all the more important in the field of mental health, where study participation has traditionally been difficult, as the symptoms of people diagnosed often rendered their adherence to specific interventions problematic, while the desire to avoid stigmatization made them reluctant to attend face-to-face meetings (Naslund et al., 2015).

Used in mental health since its early days, the Internet has importantly shaped the participation of people diagnosed in knowledge production. Already in 1999, Barak (1999: 231) noted that “the rapid developments in computers and information technology over the past decade have had an impact on psychology, which has moved (…) from local computer applications to network applications that take advantage of the Internet.” By now, numerous studies have indicated the potential (Barak et al., 2008; Carlbring & Andersson, 2006; Proudfoot, 2004; Smith et al., 2011) and variety of online interventions for mental health (Barak & Grohol, 2011; Kraus et al., 2010; Marks et al., 2007; Ybarra & Eaton, 2005). Bipolar disorder is among the mental health conditions affected by such approaches, as various online therapies and different types of mobile phone applications have been developed (Nicholas et al., 2015).

There are important differences in approach, motivation, and goals among patient organizations focusing on the same condition (Barbot, 2006) and even among members of the same group (Epstein, 1996). The Internet has helped render more visible the heterogeneity of bipolar patients, as various online platforms testify to their different needs and preferences. It has also contributed to the emergence of new types of involvement for people diagnosed with bipolar disorder, by diversifying the range of stances at their disposal. By using the Internet, they have been able to develop new skills and to acquire various resources. This has not only rendered bipolar patients more salient stakeholders, but it has also contributed to a diversification of the type of stakeholdership they could take up.

Since the emergence of surveillance medicine in the twentieth century (Armstrong, 1995), and particularly after the adoption of a consumerist culture in healthcare (Lupton, 1995), individuals have been encouraged to engage in self-surveillance practices and to actively manage their health by staying informed. The development of digital technologies has contributed to the diversification and intensification of these tendencies (Kopelson, 2009), but has also “promoted the individual expression of a personal experience of health” (Kivits, 2013:222), as people have been increasingly exhorted not only to seek information but also to share personal insights. Thus, the Internet has enabled not only patient groups, but also individuals to become influential by achieving high levels of visibility and by acquiring numerous readers. While most researchers have studied the changing identity and growing influence of patients as a result of collective actions, several academic works have highlighted the importance of particular individuals in shaping the character of patient organizations and of their interactions with medical professionals (Klawiter, 1999; Lerner, 2001). This chapter makes a contribution in this sense, by showing that some individual patients have become highly influential in mental health by taking advantage of some of the opportunities generated by the development of Web 2.0 platforms in the context of growing tendencies to responsibilize individuals for their health (Nettleton, 2004).

Among the multiple forms of self-expression the Internet has enabled, illness blogs represent a highly popular genre (De Boer & Slatman, 2014). Given their popularity, malleable architecture, and primarily individual character, blogs represent an excellent site to study the activities, knowledge practices, and alliances through which individuals achieve an influential position. Illness blogs are a specific type, as they “are used to express the experience of illness and to connect with readers via the internet” (Heilferty, 2009:1542). They differ based on their design, accessibility, and interactive character, and it is the more or less skillful combination of affordances related to these aspects that largely determines a blog’s standing.

Two Bloggers on Bipolar Disorder

On December 3, 2016, an online search using the keywords “bipolar blog” generated 12,600,000 results on Google and 6,870,000 on Yahoo. Regardless of the search engine used, the blog of Natasha Tracy, which was discussed from a different perspective in the previous chapter, and of Julie A. Fast came up on the first page of results, either directly or mentioned under rubrics such as “the best bipolar blogs of the year” on several health platforms. They are thus likely to come to the attention of many Internet users, especially since both of them can be accessed freely by readers.

Each of these bloggers has been diagnosed with bipolar disorder for about two decades. Tracy is an award-winning mental health speaker and writer on topics such as bipolar disorder, depression, pharmacology, and other mental health–related issues. She has authored three blogs—Breaking Bipolar, Bipolar Burble, and Bipolar Bites—and has been a contributor to the Huffington Post. Her blogs attract large numbers of visitors, and many of her posts receive hundreds of comments. Fast is “a world leading mental health expert on the topics of bipolar disorder, depression, seasonal affective disorder, personality disorders and mood management.” She states that her site and blog together have been visited by one million visitors. Unlike Tracy, her personal blog, Bipolar Happens!, only gathers a very modest number of comments (< 10), but there is significantly more interaction on her blog on the bipolar disorder “Hope” magazine website, Fast Talk. Fast also works as a “bipolar disorder management specialist” at Share.com, the website created by Oprah and Dr. Oz. To reach audiences of different ages, in recent years, Fast has also actively engaged in the provision of information about bipolar disorder on Instagram and Facebook.

While Internet users have been studied as health-related information seekers and/or producers, less attention has been paid to their potential as information mediators. Illness blogs are important mediation sites, as experiential knowledge is combined with medical, pharmaceutic, and socioeconomic information. These bloggers function as mediators, as they “transform, translate, distort, and modify” (Latour, 2005:39) the information they share in order to adapt it to the opportunities and limitations of the medium and to the requirements of different audiences (Wathen et al., 2008). Importantly, the development of this new stakeholder category occurs in a context where patient experiences have come to be valued, elicited in various ways online, and, subsequently, commodified (Adams, 2013; Lupton, 2014; Mazanderani et al., 2012). I argue that through their practices and collaborations with different stakeholders, these two bloggers move beyond the role bipolar patients generally have in the field of mental health, and turn themselves into a new type of stakeholder—the online expert mediator.

Theoretical Approaches to Interactional Expertise

The online activities of these bloggers are analyzed instead using the concept of interactional expertise (Collins & Evans, 2002), which bridges the divide between practical, experiential, and scientific knowledge. This notion is particularly useful, because it allows me to identify people endowed with substantial knowledge but missing official credentials, and provides an appropriate explanatory framework when studying phenomena “involving different expert communities” (Collins et al., 2017: 782). While contributory expertise denotes one’s ability to contribute productively to a field (Collins & Evans, 2007), interactional expertise “is expertise in the language of a specialism in the absence of expertise in its practice” (emphasis in the original) (Collins & Evans, 2007: Loc. 520). This means that people endowed with interactional expertise have specialist tacit knowledge and they understand the language of a domain of practice and can engage in interesting conversations with those with contributory expertise in that domain, but they cannot make practical contributions to it. Thus, people may acquire interactional expertise through immersion in a field while following a different trajectory than contributory experts (Collins et al., 2006). Interactional expertise is also highly specific: just like contributory experts in a field can contribute successfully only in some areas, interactional experts can be more competent about particular subdomains of a field. Furthermore, the acquisition of interactional expertise enables people to function as mediators between contributory experts in a field and the group(s) they represent.

Collins and Evans (2015, 2017) have studied interactional expertise using the Imitation Game, which is an adaptation of the test Alan Turing developed to assess the intelligence of computers. In so doing, they resist calls to expand the initial definition of interactional expertise in ways which they believe would diminish its “real” character. Nevertheless, in this chapter I follow the lead of scholars who have argued for a broadening of the way in which this concept is understood (Goddiksen, 2014). I thus take up Plaisance and Kennedy’s (2014) recommendation to study interactional expertise by considering the “fruitful” contributions people endowed with it can bring to a field due to “the various profiles that interactional experts can have as a result of who they are, why they’ve sought to acquire IE [interactional expertise], and how they make use of it” (Plaisance & Kennedy, 2014:65). In so doing, I extend interactional expertise by considering the effects of taking seriously the medium through which it is displayed and I show that it has more of a bi-directional character than Collins and Evans had envisaged.

I argue that there are important differences between the activities people can engage in and the approaches that they can choose from to display interactional expertise, depending on the medium they use. While some people may be able to understand their interlocutors better and express themselves more eloquently during face-to-face encounters, they may have a more difficult time displaying their interactional expertise convincingly via the telephone, in writing, or online. Furthermore, each medium might bring them in touch with different audiences, with different criteria for assessing credibility, different expectations, and informational needs. By studying the activities of Tracy and Fast on different online platforms, I identify various ways in which these bloggers make use of online affordances in order to successfully deploy interactional expertise and thereby establish themselves as authoritative figures in the field.

These two bloggers were identified using the Google index as a relevance indicator, as I aimed to mimic the approach of regular users. Data were collected between July 2014 and September 2018 and initially consisted of bloggers’ posts about the treatment of bipolar disorder and information provided under the “about” rubric of every blog. To acquire a better understanding of the bloggers’ standing and other public activities, additional online queries were subsequently conducted, using the bloggers’ names as search terms in the search engine Google. The search “Natasha Tracy” generated 19,600,000 results, while “Julie A. Fast” 349 million. The biographical and social data were collected from the first ten pages of results. I also conducted an e-mail interview with Julie A. Fast and an online interview with Natasha Tracy using the Skype telecommunications application. I performed thematic analysis of all the texts collected, including hyperlinks and images, by identifying important themes through repeated readings (Lupton, 1995). I operationalized interactional expertise based on Collins and colleagues’ approach (2006) into three main dimensions: linguistic fluency in the field of medical knowledge about bipolar disorder; ability to evaluate and distinguish between medical professionals; and ability to provide practical advice about relevant matters in the field. Given the aim of expanding the notion of interactional expertise, the following aspects were additionally focused on how and when bloggers invoked and displayed medical knowledge; the bloggers’ relations with medical professionals; the alliances they forged; elements conveying the bloggers’ standing; and the bloggers’ use of online affordances. In what follows, I discuss how these bloggers have turned themselves into online expert mediators.

Tracing the Development of a New Stakeholder Category

Technical Prowess

A first characteristic of online expert mediators is their endowment with or access to substantial technological skills. Fast and Tracy managed to become online expert mediators because they were among the first to realize the Internet’s potential and to understand how much people diagnosed with bipolar disorder needed their insights. While Tracy has a degree in computer science and used to work for Microsoft, Fast’s long-term partner at the time when she started sharing her perspectives on bipolar disorder online was a gifted programmer. She also mentioned that both of them were technology enthusiasts. In the e-mail interview I conducted with her, Fast stated that her “internet career was a perfect storm of events” (Fast, May 8, 2017, e-mail interview) and noted the role that various technologies and her partner’s abilities to make use of them played in her career:

In that EXACT moment in the spring of 2002, I had the idea that I could take my first two books and sell them as download books. No one was doing this except a few guys who were selling sales tools and real estate guides. I found NO books on the internet about any psychology topic or even any self help topics. I knew I had a good idea. (…) We spent the next month building a website to sell my two books. I turned my manuscripts into PDF files and because he was a programmer and a computer genius- we were able to build something that hardly existed at the time. An ebook website! The books were Bipolar Happens! and my Health Cards Treatment System for Bipolar Disorder. I wrote a home page- Ivan created links for people to buy the books through something called a SHOPPING CART and the business was born. It wasn’t that long ago, but can you believe that the words Ebooks and shopping cart were so new, we were not even sure what they meant. My business helped define the process. I was the first person in the world to sell a psychology or self help ebook online. (my emphasis)

I say it was a perfect storm because on the exact month that I started my webpage, Google started something new called ADWORDS. I was one of their first customers. I created an ADWORDS account and started to advertise my treatment plan from the first week it was online. This was perfect timing. Believe me, so much of what happens online is LUCK. Yes, I was prepared and I had a truly great product, but the timing was perfect. Often, you have to be in the right place in order to adapt new technology. (Fast, May 8, 2017, e-mail interview)

In this blogger’s view, therefore, her considerable influence is partly due to her innovative approach and the active role she played in the development of the field of self-help e-books from its inception.

Both bloggers credit their success to the specific character of online communication and digital technologies, which allowed them for advance planning and for the content they created to be made available to their audiences regardless of their health state at any given moment in time. Fast mentioned, “I was sick a lot- so having an internet business was a miracle for me. I could be sick and still sell my books” (Fast, May 8, 2017, personal communication), and argued that “[a]n internet business is the ONLY business I can do considering my brain limitations” (Fast, May 8, 2017, e-mail interview). At the same time, the bloggers emphasized that different online platforms afford varying degrees of control and power and that appropriate skills have to be acquired to use each type of platform to one’s benefit:

THEN, Facebook happened. I can’t tell you enough how this changed everything. MySpace simply couldn’t do what Facebook did. Facebook made talking about yourself very easy. I had a love/hate relationship with Facebook for many years. I was bullied a lot and didn’t know how to control the flow of information. Webpages and blogs are safe spaces- the author controls who says what. Facebook was a free for all. It was amazing and destructive at the same time. I now know exactly how to use it, but it’s an art. I can say the same for Twitter. (Fast, May 8, 2017, e-mail interview)

To render their online undertakings successful, the bloggers also had to call upon different types of knowledge and make wise decisions about the involvement of other professionals. Just as the Internet is multiple, so are the skills necessary to use it in one’s favor, and developing such insights requires time and numerous other resources that few people may have at their disposal. Reflecting on the important role of website statistics in her online activities, Fast stated:

It’s important to know that the internet is incredibly ALIVE- we do things that you can’t do in a regular business…So many internet business owners make decisions that are creative instead of business oriented and creative. You need both. Creative people who don’t really like looking at stats tend to just post and hope for the best. In reality, a successful internet entrepreneur always has the business in mind and must look at stats from every source possible. It’s an ever changing environment, but stats are always the friend of an online business. You can hire someone to do this, but you need to understand it yourself first. (Fast, March 20, 2021, personal communication)

Next to statistics, timing and the early development of relevant relationships seem to have been of great importance for the online careers of these bloggers. Fast’s early start using one particular online technology enabled her to be among the first to embrace many others, which allowed her to increase her online visibility: “I also feel… these three sites [her sales website, her PR page, and her blog] have helped with Google rankings” (Fast, May 23, 2017, personal communication). From this other point of view, these online technologies also contributed to important inequalities, as her status as a successful early adaptor provided her with more authority and influence than people who started using them later, thereby enabling her, based on her own admissions, also to shape the genre of illness blogs.

Interactional Expertise

Next to technical skills, Fast and Tracy also needed to develop and perform interactional expertise about medical knowledge on bipolar disorder to successfully function as online expert mediators. The display of linguistic fluency in a field is the main mark of people endowed with interactional expertise (Collins & Evans, 2002). While Tracy and Fast are not medical professionals, nor did they study medicine, the many years since they have been diagnosed with bipolar disorder, the multitude of treatments they have tried, and the great variety of professionals they have consulted have provided them with ample opportunities to observe the practices of the medical community. Furthermore, their own proactive attitudes have enabled them to deepen their medical knowledge about bipolar disorder. These bloggers display their linguistic prowess throughout their posts and interactions with commentators, as they explain medical phenomena using a more accessible vocabulary and providing examples, they give advice about the most appropriate therapeutic approaches depending on one’s symptoms and/or life circumstances, and they are aware of the latest developments in the field. The excerpt below is illustrative of such activities:

Drug tolerance is also known to occur upon drug-discontinuation. In other words, someone who has previously responded well to lithium discontinues the drug, symptoms reemerge, the person goes back on lithium but does not find it effective. Again, we don’t know why this occurs but it does appear to in a small percentage of patients. In one study, it occurred in 13.6 percent of people taking lithium.

(…)

Warning, this is a preclinical study and as such the implications from it may not be fully understood. Please make sure to make any medication changes only with doctor oversight. For more information please see the study Tolerance to the Prophylactic Effects of Carbamazepine and Related Mood Stabilizers in the Treatment of Bipolar Disorders [hyperlink provided]. (Tracy, Bipolar Bites, May 30, 2012)

This quote indicates Tracy’s position as mediator between medical professionals and bipolar patients, a position which I argue is characteristic for this new type of stakeholder. While it may be that it refers to the level of knowledge available to the whole of humanity, the use of “we” in a context where study results are discussed suggests that Tracy sees herself more as a member of the medical community. At the end of the post, however, she reclaims her subordinate position to medical professionals, while by sharing the source she used, Tracy reveals her awareness of the need to legitimize her claims.

Mediators importantly transform the meaning of the information they transmit, and this is obvious in the posts authored by both bloggers. While they convincingly use medical vocabulary, they do so in particular ways. For instance, in a manner which reiterates the tactic of individualization discussed in the previous chapter, Tracy puts forward her own reading of personalized medicine, as on numerous occasions she seems to believe that each person displays an individual mix of symptoms and reacts differently to treatment, as the quote below illustrates:

And if 99 people say the med is bad, but 1 says it’s good, what benefit is that? Should the patient not try it? Should the patient assume the med won’t work or will have too many side effects? The 99:1 ratio essentially means nothing because we’re all different. (Tracy, Breaking Bipolar, June 30, 2011)

Furthermore, Tracy often uses statistics and results obtained through randomized controlled trials to support her claims. This shows that she makes strategic choices about the ways in which she refers to medical information, an approach previously identified among patient organizations (Treichler, 1999). This rather complicated balancing act is necessary as it allows her not to alienate readers with experiences different from the ones she describes while maintaining her authority. At the same time, it enables her not to stray too far from the prevailing medical consensus, thereby retaining her ties with the medical community.

The bloggers display their linguistic prowess also by distinguishing between different medical professionals in the field of bipolar disorder, and they often criticize the prescription habits of general practitioners, as the quote below illustrates:

Interestingly, many fewer people being treated by bipolar disorder experts are on antidepressants:

• Treated by community psychiatrists—80 percent of patients are on antidepressants

• Treated by mood disorder clinics—50 percent of patients are on antidepressants

• Treated by specialty bipolar clinics—20 percent of patients are on antidepressants

So it would seem that the more specialized the care, the more professionals recognize the concerns over antidepressants. (Tracy, Breaking Bipolar, July 10, 2013)

As such views are expressed in posts where they provide the latest insights into a particular treatment, it would appear that these bloggers position themselves as more up to date than some medical professionals. Collins and Evans’ (2002) conceptualization of expertise is based upon the idea that no contributory expert is equally competent in all areas pertaining to a particular domain. From this point of view, it remains open for debate whether these online contributions are attempts to fill relevant epistemic gaps or whether they represent interventions through which the bloggers challenge the authority and standing of medical professionals who are lower positioned than specialists and scientists, for instance.

This ambiguity is further exacerbated by the fact that such online comments are balanced by entries where Tracy and Fast warn readers about their lack of medical credentials and take up a complementary function to medical professionals. They try, for instance, to prevent people from quitting their medication when scandals related to pharmaceutical companies emerge. Fast even depicts herself (and people diagnosed) as useful allies, helping doctors identify dishonest claims made by pharmaceutical companies through their experiential knowledge of the effects and side effects of medications (Fast, Bipolar Happens!, October 16, 2016). Furthermore, multiple entries (Tracy, Breaking Bipolar, July 5, 2012) show that through their immersion in the community of medical professionals, these bloggers have also become familiar with the political economy of the pharmaceutical industry.

Another way in which they display their fluency in medical knowledge is by evaluating the merits of various studies and by distinguishing between medical information based on its source. In so doing, Tracy and Fast often clarify the status of the knowledge on bipolar disorder currently available and the inferences that can be made on it, as the following excerpt indicates:

It’s time to get clear on what we really know about brain scans and #bipolar. It’s so frustrating to read articles and studies about bipolar and brain imaging. At this time, there is NO brain image scan for the diagnosis of bipolar. Please do not pay someone who tells you that they can determine bipolar from an MRI or PET scan. It simply isn’t true.

This is nascent science. One study shows some grey matter thinning in 3000 patients, another shows ‘abnormal’ activity in the amygdala and frontal lobes. There is nothing definitive and even if someone did find a change in the brain, without having a management plan that works, the information is just that… information. (Fast, Bipolar Happens!, July 18, 2018)

Fast performs interactional expertise by showing her familiarity with medical technology and terminology, and by being able to distinguish hopes and visions from the current relevance of brain scans in the diagnosis of bipolar disorder. Concerned about the quality of information that people diagnosed may acquire even from medical sources, Fast positions herself as a mediator, by using her own knowledge in order to correct erroneous assumptions and expectations. The bloggers also perform interactional expertise through their careful selection of the sources of information they use in their posts, as the excerpt below shows:

I’m pretty fussy about which medical and mental health resources I like, and which ones I don’t. While there are many bipolar and mental health resources out there, I’m only interested in accurate verifiable and reliable sources of information on bipolar disorder and mental illness. (Tracy, Bipolar Burble, Bipolar and Mental Health Resources,¹ emphasis in the original)

Through their online posts, Tracy and Fast thus show that they have become fluent in the language of medical professionals and have therefore successfully developed interactional expertise.

A Strong Media Presence

While important, having (access to) considerable technical skills and developing interactional expertise are not sufficient for these bloggers to become online expert mediators. To function as successful mediators between medical professionals and people diagnosed, Fast and Tracy not only require ample opportunities to perform interactional expertise, but they also need a strong media presence, to increase their public visibility and standing. The two bloggers have achieved this by developing close relations with mass media outlets. Tracy has often been interviewed and has participated in documentaries about bipolar disorder. In 2008, Fast hosted a weekly radio program, The Julie Fast Show, on KTRO in Portland, during which she had a number of “special guests,” medical professionals or people diagnosed with various mental health conditions, who often wrote about their experiences and participated in advocacy actions. She is regularly interviewed on diverse mental health issues, such as pop artist Britney Spears’ nervous breakdown and actress Carrie Fisher’s death, and writes on mental health in magazines such as People and US Weekly. Fast was also the original consultant for the character played by Claire Danes, the main protagonist who suffered from bipolar disorder in the popular drama series Homeland. Fast and Tracy have also published books about their experiences with bipolar disorder, thereby further extending their reach. In 2016, Tracy wrote Lost Marbles: Insights into My Life with Depression and Bipolar. Fast is the author of five books, which have sold over 250,000 copies, four of which are “on the Amazon.com mood disorder bestselling book list” (Fast, Bipolar Happens!, 2016).

Through such activities, the bloggers also reach broader audiences than bipolar patients and their families, thereby contributing to how bipolar disorder and other related conditions are understood by the general public. As they become more familiar with other media, these bloggers can use their skills for more political purposes, as they may generate public sympathy, emphasize the urgency of particular pieces of legislation or treatment provisions, or put forward more complex images of life with bipolar disorder. In so doing, Tracy and Fast expand their mediation work beyond the more immediately responsive online medium, translating, synthesizing, bringing together, and refining different types of knowledge about bipolar disorder in formats in which interaction is more difficult, takes more time, and occurs more frequently away from the public. Yet, it is precisely through their ability to use different media and to retain a coherent image across them that these bloggers further increase their influence and standing.

That their standing goes beyond that of the average blogger is indicated by the numerous awards Tracy and Fast have received. Tracy received the Beatrice Stern Media Award and the #ErasingtheStigma Leadership Award and has been listed as the fourth Health Maker in the top ten online influencers in the area of mental health by Sharecare.com. She was also a speaker at the National Council on Mental Health and Addictions Conference and is hailed as one of the “heroic” figures of people diagnosed with bipolar disorder. Another indicator that her reach goes beyond the small circle of family and friends of regular illness bloggers is the fact that she has been a contributor on health platforms and a subject matter expert on bipolar disorder at Answers.com, all of which have millions of visitors. Fast received the Mental Health American Journalism award for the Best Mental Health Column in the US. Furthermore, the blogs Tracy and Fast have authored have been voted many times among the best bipolar blogs.

Whereas Fast and Tracy’s activities across multiple media help them acquire greater audiences, the distinctions they received function as references or recommendations. Consequently, they can use their public visibility and standing as important resources to facilitate the development of more varied and substantial collaborations, not only with people diagnosed, but also with medical professionals. While this is an important characteristic of online expert mediators, in the next part of the analysis I use these insights to make a theoretical contribution, by expanding the notion of interactional expertise. I do so by arguing that interactional expertise has a stronger bi-directional nature than Collins and Evans assume and that the effects of the medium through which interactional expertise is performed need to be taken seriously.

Online Practices and Theoretical Implications for Interactional Expertise

Substantial Interactions and Bi-directionality

Bi-directionality refers to the ability of people endowed with interactional expertise to function as mediators between others with the same kind of contributory expertise as they and with individuals who have contributory expertise in the field where they hold interactional expertise. Whereas bi-directionality is an important aspect of interactional expertise, Collins and Evans do not sufficiently theorize it. For Collins and Evans (2002), interactional experts translate the scientific practices of contributory experts in one field for people with contributory expertise in another field, and shape the knowledge contributory experts produce by questioning some of their practices or by making them aware of other perspectives on an issue of interest. Thus, Collins and Evans see interactional experts as providing contributory experts with sources of inspiration. Whereas they see such exchanges as taking place in both conditions of symmetry and asymmetry, in the latter case, they only seem to conceive of one direction for the acquisition of interactional expertise, as I explain below.

Collins and Evans (2002) do not provide much information about the acquisition of interactional expertise in conditions of symmetry, but they suggest that it occurs between experts who may find themselves equally well positioned in order to productively contribute to the solution of a certain problem. In such conditions, Collins and Evans (2002) state that any of the two groups may absorb the expertise of the other one by developing interactional expertise. One may imagine such a situation occurring, for instance, as two different types of medical professionals are consulted for the treatment of a difficult case. Which one of the two specialists takes charge and oversees the patient’s treatment is “arbitrary” from Collins and Evans’ point of view, as long as one of the doctors has or develops interactional expertise into the other medical field, in order to be able to make informed decisions about the therapeutic approaches based on relevant insights from both medical fields. While in this example, the two contributory experts need to solve a common problem, Collins and Evans (2002) also give examples of situations where interactional expertise is developed by experts to address their own specific goals. For instance, they often invoke sociologists, who need to become fluent in the practice language of the scientific group they study, to be able to successfully conduct a sociological analysis. In such cases, however, Collins and Evans (2002, 2017) conceive of the development of interactional expertise as the responsibility of the group doing the study or needing to solve a specific problem.

Collins and Evans (2002) tie the development of interactional expertise under conditions of asymmetry to instances when this type of expertise is needed to facilitate the integration of a certain (sub)type of contributory expertise into another, broader, form of contributory expertise, with which the first is continuous, for the satisfactory resolution of a complex problem. They give examples both of situations when third parties are involved and of instances when the integration of one type of expertise into the other occurs without external involvement. In the first case, Collins and Evans (2002) mention that such absorption may be mediated by people who are not contributory experts in any of the two fields, but who hold interactional expertise in both. For instance, a sociologist may translate the knowledge and perspectives of a (smaller) group of unaccredited and less influential experts into a language that the accredited experts can understand, in order to appreciate and be able to use the insights of the unaccredited experts to solve a common problem.

When discussing the development of interactional expertise under conditions of asymmetry, Collins and Evans (2002) tend, however, to ascribe the task or capability of acquiring interactional expertise to the group of experts which are better positioned to solve a certain problem because of the epistemic authority, legitimacy, and other resources they already enjoy. Thus, they provide a new reading of Wynne’s (1992) study on the relationship between scientists and the Cumbrian farmers in the aftermath of the Chernobyl disaster, where the scientists failed to recognize the contributory expertise of the farmers, who lacked official accreditation. Collins and Evans (2002:255) state that for the farmers’ insights to be taken seriously, the latter “would not have had to engage in a symmetrical conversation” (emphasis in the original), but the scientists would have had to be willing to incorporate the former’s insights by developing the relevant interactional expertise. Another example testifying to the same perspective is that of medical professionals becoming interactional experts on the lived experiences of their patients, which Collins et al. (2017) more recently invoked. Importantly, in Collins and Evans’ (2002:256) view, “only the party with interactional expertise can take responsibility for combining the [contributory] expertises.”

This argument suggests that under conditions of asymmetry, Collins and Evans believe the more influential party has the necessary resources to develop interactional expertise. I argue, however, that interactional expertise can not only develop in a bottom-up direction, whereby stakeholders who already enjoy epistemic authority in a given field expand their expertise by absorbing knowledge from unofficially recognized contributory experts in a (sub)field of interest, but it can also be acquired in what may seem like a top-down manner. Thus, people who have contributory expertise in a field but are not officially accredited can become fluent in the practice language of relevant epistemic groups, if they are endowed with other necessary resources. The acquisition of interactional expertise might this way contribute toward the development of more symmetric relationships between people who enjoy different standing due to the status of the field in which they have contributory expertise. As the description below will show, even under conditions of asymmetry, people endowed with interactional expertise can engage in exchanges that are more substantial than having interesting conversations with contributory experts, as Collins and Evans (2002) believe. Furthermore, whereas in determining the (a)symmetric character of an interaction, Collins and Evans seem to focus mainly on epistemic standing and authority as the determining factors, I argue that the availability of other resources may help balance such exchanges. More attention should therefore be paid to the type and quality of the interactions between interactional and contributory experts in different fields and to how different conditions or types of asymmetry may affect them. The exchanges of the bloggers studied here are revelatory in this sense.

One of the challenges encountered by researchers interested in collaborating with patients is to enable their contributions (Hewlett et al., 2006). This is an area where online expert mediators engage in mediation work, as they succeed to develop a space where their readers can articulate their experiences and negotiate how they position themselves in relation to their condition and the medical community. The bloggers educate people diagnosed about medical terminology and perspectives, so that the latter are better able to engage in collaborative projects with researchers. This is important, because not all bipolar patients may have the time and be in the physical and mental state necessary to grapple with medical terminology and research methodology. Moreover, Tracy and Fast may provide people diagnosed with the confidence that the insights they have are relevant and valuable, thus enabling them to interact with medical professionals with the assurance and determination necessary to move toward more equal exchanges. They may also help those interested in research participation to develop the patience and distance necessary to accept results, which may contradict their personal views.

Next to bipolar patients, the bloggers have constituted themselves as valuable allies for medical professionals who lack but need their insights derived from the lived experience with bipolar disorder for various aims. Thus, online expert mediators can assist medical professionals to acquire interactional expertise regarding the embodied experience of bipolar disorder, and thus help them develop a broader perspective about this condition and novel research ideas. By positioning themselves as representatives of their bipolar readers, the bloggers provide medical professionals with important information regarding the research directions people diagnosed with bipolar disorder would find relevant. In a context where medical expertise continues to be challenged, online expert mediators further serve the interests of the medical community by bestowing additional credibility upon the scientific approaches they champion.

The bloggers have also acquired sufficient medical knowledge and other relevant resources for medical professionals to agree to collaborate with them. Tracy noted that

in my role I’ve been lucky enough to meet some really great professionals, some really great psychiatrists and researchers in their own right. And because I’ve gotten to know them through various acquaintances and through various things that I’ve done, if I want to do something that is scientific in nature, which I have done, then I can actually approach them and say: “Look, I really have an interest in doing this. Do you have an interest in supporting this?” And we can work together to make it happen. (Tracy, March 29, 2021, online interview)

For instance, together with Prakash Masand, M.D., Tracy wrote an article published in 2014 in the medical journal The Primary Care Companion for CNS Disorders. Furthermore, in July 2016, she initiated a survey about patients’ experiences concerning electroconvulsive therapy (ECT) on her personal blog:

My name is Natasha Tracy and this ECT survey was my idea. I am running this survey with Dr. Prakash Masand [hyperlink provided], the psychiatrist behind the site Global Medical Education [hyperlink provided] which aims to educate others, particularly doctors, about medical issues such as those surrounding mental illness.

For my part, I have bipolar disorder and have had ECT for bipolar depression. This has made me passionate about the subject as I see the extreme debate that goes on about this treatment online. (Tracy, Bipolar Burble, July 3, 2016)

While she is knowledgeable enough to come up with this idea and for an authoritative medical figure to collaborate with her, Tracy needs this partnership to legitimate her endeavor, since she lacks the apparently still necessary official accreditations.

Like Tracy, Fast has also used her blog to encourage people to participate in studies she champions:

Can We Diagnose Bipolar Disorder Using Eye Images? (…)

This is the question a new study from Souther [sic] Methodist University poses based off of my work on recognizing signs of mania in the eyes. Please visit the website and read more about this potently life changing study. What if we could see that we are manic through a physical sign even when our brain is telling us we are just fine? Think of the possibilities.

Click here to read more about the SMU Mania in the Eyes Research Study. [hyperlink provided]

If you love my work, I would love your support of this project. Even one picture helps! (Fast, Bipolar Happens!, September 27, 2017)

Both excerpts suggest that one of the ways in which this new type of stakeholder can make themselves interesting for medical professionals to want to collaborate with them is by using their popularity among people diagnosed with bipolar disorder to encourage them to provide the data scientists need for research. While medical professionals acquire through such collaborations much needed data, the bloggers profit from the credibility and legitimacy of research findings obtained through collaborations with officially recognized experts, as Tracy notes

I don’t have the credibility behind me in terms of getting published in a journal. So it’s very important that I collaborate with someone who does, so that the results of something can be published in a way that not just people on my blog are going to see, but actually doctors are going to see, and doctors are going to respect. Because I can be the best writer in the world or the worst writer in the world … if I run a blog, doctors aren’t necessarily going to pay attention to that whatsoever. It’s understandable. But publishing something in a journal, that’s going to get their attention. And I, just Natasha Tracy, can’t really expect to do that very reasonably. (Tracy, March 29, 2021, online interview)

More such collaborations may develop in the future, given that the expertise of these bloggers about bipolar disorder has been publicly acknowledged by medical professionals. For instance, Ronald Pies, M.D., wrote about Tracy:

As a specialist in bipolar disorders, I can say that Natasha’s understanding of this illness is more accurate and sophisticated than that of many physicians I have encountered over the past 30 years. But more than that: she shows uncommon wisdom and deep compassion, when it comes to discussing psychiatrists and psychiatry. (Pies, Psychiatric Times, May 24, 2012).

In her turn, Fast has co-authored the books Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability (2004), Loving Someone with Bipolar Disorder (2004), and Get It Done When You’re Depressed (2008) together with Dr. John Preston. He is now professor emeritus with Alliant International University in Sacramento, the author of 21 books, and the recipient of the “President’s Award” from the Mental Health Association and of “Distinguished Contributions to Psychology Award” from the California Psychological Association. Fast is also claimed to “train pharmacists, psychiatric residents, social workers, alternative health care practitioners, general physicians, nurse practitioners, therapists and many more health care professionals on the topics of depression and bipolar disorder management” (Amazon, 2016). Reflecting on The Health Cards Treatment System for Bipolar Disorder, which she developed for people diagnosed with bipolar disorder and their family members, and which “works with or without medications,” as she claims (Bipolar Happens!, 2016), Fast states: “I know that tens of thousands of my readers use the Health Cards daily… (…) Even my health care professionals use them!” (Fast, Bipolar Happens!, May 6, 2010). While using Fast’s cards attests to an awareness by medical professionals that bipolar patients and their families may have needs which traditional medical approaches insufficiently address, it may also be a means for them to retain monopoly over medical knowledge at a time when other professionals challenge it. For the time being, however, both Fast and Tracy as well as the medical professionals they work with profit from forging alliances, and such substantial exchanges are characteristic for the activities of online expert mediators.

These bloggers are thus more than interesting and inspiring conversation partners for medical professionals. They are stakeholders that researchers want to collaborate with substantially, as they can facilitate the enrolment of a high number of study participants, and they can provide experiential knowledge and important insights into relevant areas for future research. The way for such partnerships has already been paved by patient organizations, but there have also been several substantial collaborations between researchers and particular individuals. Notable in this sense are the research activities of Portia Iversen (Iversen, 2007) and Sharon Terry (Terry & Boyd, 2001), who have directly contributed to the development of new therapeutic approaches for autism, and to the identification of the gene mutation causing pseudoxanthoma elasticum (PXE), respectively. Yet, whereas Iversen and Terry had control over important resources as the leaders of two influential patient groups and were not themselves diagnosed with the conditions they studied, Tracy and Fast are bipolar patients and have managed to acquire the resources mentioned above individually, through their skillful use of the Internet.

Interactional Expertise and the Use of a Specific Medium

In their conceptualization of interactional expertise, Collins and Evans do not consider the effects of the medium through which interactional expertise is produced. I expand this notion by showing that the Internet has importantly shaped how Tracy and Fast have performed their interactional expertise. Studying how the Internet shapes the performance of interactional expertise is particularly important, since “in the context of the digital shift, the demarcation between certified experts and lay people is blurring” (Dickel & Franzen, 2016:3). This topic has generated a lot of interest among scholars in the field of science education and science communication, who have studied how the public responds to or engages with scientific knowledge provided via different media. Important in this sense is a study conducted by Shanahan (2010) on how scientific and personal expertise about health was expressed and discussed in the online comments section of a newspaper. Her study showed that even in peer-to-peer interactions, the most appreciated comments were those of contributors who claimed (some level of) scientific rather than personal expertise. Even though the online exchanges between the blog authors studied here and their readers may be conceived as peer-to-peer interactions due to the shared diagnosis of bipolar disorder and certain embodied experiences, there are important differences that need to be considered. Unlike the contributors scrutinized by Shanahan (2010), Tracy and Fast are individuals with a well-established public persona, who have to further demonstrate the interactional expertise displayed in their posts by (not) engaging with their readers’ comments. While their audience may include contributory and interactional experts, an important difference from Shanahan is that such exchanges already take place in conditions of inequality, since as authors and owners, the bloggers speak to their readers, as some of the quotes provided above indicate. Shanahan’s findings are nevertheless relevant, showing that online scientific expertise is not determined based on the invocation of credentials, but on one’s ability to take up scientific practices, such as the provision of evidence and the citation of relevant sources, thereby revealing one’s familiarity with the scientific norms and culture.

Such approaches were adopted by Tracy and Fast as a means to articulate and reinforce their online standing. For instance, comments from readers are used as opportunities to display their expertise by giving additional medical information and by correctly identifying specific interventions. Since people with experiential expertise display growing tendencies toward scientization in their contributions (Shanahan, 2010), these bloggers do not merely invoke scientific claims, but carefully select, apply, and interpret them. This is how Tracy reacts to a vague comment about a new test meant to determine the effectiveness of medical treatments for bipolar disorder: “I believe you’re talking about the cytochrome P450 (CYP450) tests which I know are offered at the Mayo Clinic. (Also used in cancer treatment)” (Tracy, Breaking Bipolar, November 5, 2012). Thus, apart from having sufficient knowledge to understand what the contributor is referring to, Tracy also contextualizes the test, linking it to other medical disciplines. The bloggers further use their readers’ comments as indicative of their informational needs and as sources of inspiration for some of their posts. From this perspective, comments help bloggers retain their popularity and influence by addressing topical issues.

Yet, the Internet also poses challenges to the display of interactional expertise, as the information they provide is open to the scrutiny of people with different levels of education, different views, and at different moments in time. To become and remain credible mediators, Tracy and Fast therefore need to show that the knowledge they share is authoritative while staying open to different perspectives. One way in which they manage such contradictory expectations is by using the Internet’s multiplicity, giving different nuances to their messages on different platforms. They further use the asynchronous and selective character of comment exchanges to react advantageously to their readers’ unexpected questions or reactions. Since Tracy and Fast are at liberty to choose when they react to comments, they can take the time to acquire more information or to work on a reply until it has a satisfactory shape. In the meantime, other readers may come to their “help,” by sharing their knowledge and experiences. The bloggers’ successful display of interactional expertise is also informed by the wise selection of instances when they interact with their readers. Thus, while they choose to intervene in situations where their knowledge, empathy, and relatability are emphasized, they remain silent in front of provocations which may alienate their audiences. Comments rules are another important instrument through which the bloggers may contain their readers’ challenges and avoid controversy. For instance, initially Tracy did not allow commentators to provide the exact names and dosage combination of medicines. While this approach was meant to prevent readers from trying medicines without medical approval, it also weakened the epistemic claims and challenges they could bring against her.

The technology of blogs also enables Tracy and Fast to display their interactional expertise using images and hyperlinks. Their blog entries are often accompanied by images which either illustrate the main message of the post or bring an additional dimension to the information provided in writing. Depending on the topic, the bloggers choose for different ratios between written material and images. For instance, when discussing alternative ways of ensuring mood stability, Fast only writes a few lines but provides numerous images depicting relaxing activities. When the effects of particular medications are discussed, however, the written text dominates. At the same time, both bloggers provide videos of themselves on the blog, where they talk about certain experiences or advise their audiences. While it may be that their use of videos is informed by curiosity and by the desire to experiment with new technologies and opportunities available to update their blogs, such videos also serve to enhance the authenticity of their accounts, and to strengthen the bond between themselves and their readers. Through the use of video, the person behind the text of many posts, books, and magazine articles becomes a three-dimensional being, who moves and talks in particular ways, whose appearance may reveal the presence of bipolar disorder, or who may be the embodiment of its successful management.

Hyperlinks reveal important alliances as well as power relations. Both bloggers use them in order to show that the information they provide is based on reliable sources. They refer mainly to articles available in medical databases such as PubMed and Medscape or to posts by medical professionals on platforms where they collaborate. Tracy and Fast thus position themselves as trustworthy mediators between reliable sources of medical knowledge and interested audiences. Hyperlinks are also used by bloggers to emphasize their vast body of work. For instance, Tracy uses them to direct readers to her older posts. Interestingly, the bloggers generally refrain from using these affordances to share knowledge produced by other people lacking accreditations or to introduce their readers to projects initiated by “citizen scientists.” This indicates that the high standing these bloggers enjoy is not due to a subversive use of the Internet, but rather due to their alliances with powerful stakeholders.

It is important to note that there are also significant differences between the ways in which Tracy and Fast use the Internet. Tracy’s blog is highly interactive, having posts which acquire hundreds of comments, and she uses integrated approaches to increase the visibility of new posts. Thus, Tracy often uses Twitter and Facebook to notify readers about news on her blog, while Twitter updates are provided on her blog’s main page. That interactivity is very important to her can also be derived from the fact that very popular blog posts and the posts with the most recent reactions are also listed on the first page, as you can see in Fig. 5.1, thereby guiding visitors on her page and encouraging them to engage in specific actions.

Fig. 5.1

Fragment from the first page of Natasha Tracy’s blog, Bipolar Burble. Retrieved on January 8, 2019

On Tracy’s blog, the number of comments each post acquires is listed below the title and a hyperlink is provided, so that interested readers can directly access them rather than read the post. The hyperlink also draws attention to the comments visually, since it is provided in blue whereas the remainder of the information about a specific post is typed in black.

The number of comments available for the posts is not directly visible, but readers need to press an additional button to see them (Fig. 5.2), and the comment function is not available for all posts. Unlike Tracy, her posts generally receive a small number of comments, yet her blog continues to be voted among the best bipolar blogs currently available. To a certain extent, the limited interactivity on Fast’s blog may be due to the fact that it developed as a continuation of a newsletter, so she may be accustomed to use the blog mainly to share information. Since many of her blog posts contain hyperlinks to her contributions in the online forum of bp Magazine, it may be that Fast prefers to have only one designated platform at a time for online interactions and to have ascribed this function to the forum. It may also be the case that she prefers personal correspondence with her readers, since she mentioned answering hundreds of letters per week at the time when she had just started circulating her newsletter, a habit which she may have preserved.

Fig. 5.2

Fragment from the blog posts’ overview on Julie A. Fast’s blog, Bipolar Happens! Retrieved on November 5, 2018

In general, both bloggers adapt the combination of medical and experiential knowledge, so that it is in line with the type of platform they contribute on, they react to comments strategically, and they are very careful in their use of hyperlinks. Thus, their display of interactional expertise is importantly shaped by their use of blog affordances.

Discussion

The bloggers discussed here can be seen as a particular and highly successful form of entrepreneurial selves (Petersen & Lupton, 1996). While this new type of stakeholder—online expert mediators—may fulfill a complementary or additional function to social movements, it also represents a move away from them and a focus upon exceptional patient figures, who have been able to use various resources and the opportunities and limitations the Internet has made available to become highly influential. This stakeholder category emerges thus at the intersection between a (mental) health condition, the acquisition of particular types of knowledge, and the use of a specific medium. By combining personal experiences with medical knowledge, Tracy and Fast have gone beyond the average illness blog, where one’s personal experiences are conveyed in an intimate, diary-like fashion, and have come closer to issue-based blogs, where different types of information considered relevant about a particular topic are provided and discussed using arguments and multiple perspectives (O’Neil, 2005). The interactional expertise that they develop and articulate to various degrees has a strong bi-directionality, as they need to be fluent in the language of medical knowledge of bipolar disorder as well as to retain their experiential knowledge in a format which allows them to relate to readers diagnosed with bipolar disorder and their families. Thus, in their acquisition and articulation of interactional expertise, online expert mediators are reminiscent of journalists, who “develop different degrees of bipolar ‘interactional expertise’, specializing in interactions with their sources on the one hand and audiences on the other” (Reich, 2012:339). Furthermore, the online and offline activities of these bloggers foreground the importance of focusing on the multiple shifting identities that stakeholders can call upon in their development and performance of expertise. Their highly influential position was achieved through their ability to skillfully switch between their identity as individuals diagnosed with bipolar disorder, as successful blog owners, as representatives of many people diagnosed with bipolar disorder, and so on. I have taken up these insights in the conceptualization of expertise I put forward, where expertise is approached as a practical achievement realized through coordination and affective labor among stakeholders who occupy multiple and shifting positions within a complex ecosystem.

The rise of these stakeholders takes place in a context in which the informational and health imperatives require people to assume responsibility about their health (Kivits, 2013), yet the difficulties of living with a particular condition may lead them to prefer to follow someone else’s lead (Lemire et al., 2008). Since the expertise of medical professionals has been challenged over the last few decades, many people diagnosed may seek to resolve this tension by following the advice of this new stakeholder type, by using such expert bloggers as arbiters. At the same time, the rise of this new stakeholder is also due to patients and their families requiring, apart from medical information, also encouragement and guidance. Nevertheless, these new stakeholders are also confronted with suspicion given the varying quality of the health information available online and the growing awareness that many public speakers and opinion setters represent particular groups of interest. To be successful, online expert mediators therefore need to convince their readers to develop different types of trust: they must trust the bloggers; they must trust certain online spaces or platforms; they must trust (at least) the branches of science the bloggers themselves rely upon (Harris et al., 2011). This also shows that the type of expertise these new stakeholders have acquired and perform online is a practical achievement, which they have realized by moving back and forth between relevant groups within the particular healthcare ecosystem in which they operate, by choosing to highlight particular aspects of their identity depending on the context and their goals, and by being caring but also careful toward other people and other types of knowledge.

Importantly, this chapter has indicated that the medium plays an important role in how interactional expertise is performed, thereby extending Collins and Evans’ conceptualization of this notion. In so doing, it has also brought into relief some problematic aspects concerning the development of this new stakeholder category. While interactional expertise is necessary for this new type of stakeholdership, a strong medium is also needed. Developing interactional expertise has enabled Tracy and Fast to gain access and to develop close contacts with medical professionals, yet it is their online popularity, which has provided them with the resources necessary to engage in substantial exchanges with the latter. The Internet has therefore allowed them to convincingly position themselves as representatives of people diagnosed with bipolar disorder in their relations with medical scientists in a way that is reminiscent of the approach taken up by the American AIDS activists described by Epstein (1996). Epstein problematized the position “lay experts” occupy in relation to the “lay lay,” highlighting that the acquisition of competence into a new type of knowledge impacts how one understands and relates to the other types of knowledge with which one is endowed as well as on one’s relations to others. Thus, he warned that by “learning the language and culture of medical science” (Epstein, 1995:417) people diagnosed risk distancing themselves from other people diagnosed with the same condition, from their views and interests. From this perspective, the close collaborations the bloggers develop with medical professionals may lead to a further obfuscation of the differences in experience, interests, needs, and values that exist among the people diagnosed with bipolar disorder (Rowland et al., 2017) who follow their blogs.

While blogs have been acknowledged as technologies with a democratizing potential (Huovila & Saikkonen, 2016), the findings presented here show that online expert mediators acquire such high standing by developing close ties with “traditional” experts. Thus, rather than contributing to opening the field of scientific knowledge production to more people who lack official credentials, online expert mediators might inadvertently contribute to the refinement of existing hierarchies in the relations between medical professionals and patients. From this perspective, it is regrettable that the interactions between these bloggers and medical professionals occur most of the time offline or through private communication, so that it is not possible to observe how they negotiate participation in various projects and support for various initiatives. Since the bloggers’ interactional expertise is limited to particular areas of medical knowledge on bipolar disorder and does not exclude personal preferences, online expert mediators also risk presenting their readers a skewed perspective on the use and effectiveness of the currently available forms of treatment. On a more positive note, the online expert mediators studied here may help bridge the digital divide when it comes to medical literacy by sharing medical knowledge in an accessible manner, by making people diagnosed and their families aware of the options at their disposal, and by helping them get in touch with support groups and other organizations. Having achieved a highly influential position, in the future they might harness their creativity and various skills to contribute in novel ways to the proliferation and diversification of collaborations between people diagnosed and medical professionals.

Ironically, whereas Fast started her online career after she moved to France, no French online bloggers enjoying similar standing to her and Tracy were identified. Since the use of the Internet for mental health–related purposes has been promoted by French authorities, as Chap. 3 has indicated, and since many people living in France have access to the Internet, this is a rather puzzling finding. It is all the more surprising since the results described in Chap. 4 revealed that French online contributors were supporters of active forms of patienthood, and tried to actively manage their condition and to contribute to new knowledge about treatment effectiveness. The absence of this new type of stakeholder in France might be linked to particular social and cultural elements, which shape the use of the Internet and how people relate to their condition. While numerous French blogs on bipolar disorder could be identified, either they were read by few people or they had a very limited interactive character, receiving five comments or less for most posts. There were also blogs on bipolar disorder which enjoyed greater visibility, as they were authored occasionally on the online platforms of reputed French newspapers, such as L’Avventura, a caricature-based blog authored by Fiamma Luzzati for Le Monde, or La Vie d’un Bipolaire, authored by W. on the website of L’Express. Nevertheless, even in these cases, the level of interactivity was low. This might be informed by specific French cultural understandings and approaches to blogs, which conceive of them as online spaces where different types of information can be shared in a concise manner rather than as interactive platforms. This view is supported by the fact that even when famous medical professionals decided to share their views on blogs, these were not accompanied by a comment function. The fact that such medical professionals had become famous through their activities on radio and television suggests that rather than using the Internet to become influential, in France people use it as an additional medium, to reach more audiences or to convey the image of someone who is also up-to-date regarding online technologies.

Another explanation is that the absence of such influential individuals diagnosed with bipolar disorder or with any other condition, for that matter, may be due to the fact that the imperative for people to become active patients and assume responsibility for their health may have led in France to the development of entrepreneurial subjectivities that manifest themselves differently. An example in this sense is Bipote, the administrator and founder of Le Forum des Bipotes (LFB), mentioned in the previous chapter, who was also diagnosed with bipolar disorder. Even though as forum administrator, he had significant power and control, his position there was not as prominent and as influential as that of the bloggers studied here, despite his substantial knowledge about bipolar disorder. His preference for a forum rather than a blog may denote a preference for collective enterprises rather than individual approaches, and it may be that more people in France share this attitude.

The lack of this new type of stakeholder in the French landscape may also be informed by the fact that patient associations remain highly influential there, as they are active mediators between medical professionals, individuals diagnosed, and their families. As such, there may be little need among people diagnosed for this new type of stakeholdership to develop, whereas researchers and other official institutions may prefer to engage in collaborations with patient representatives they are familiar with and who are endowed with multiple types of knowledge and vast resources to mobilize people.

To conclude, the analysis of the activities of Tracy and Fast has provided important insights regarding some of the conditions necessary to become online expert mediators. Thus, next to an official diagnosis, people’s health needs to be stable enough for them to engage in various activities requiring a lot of time and energy. They also need to be able to communicate in ways which can capture and retain the interest of different stakeholders. Furthermore, those interested need either to financially afford giving up their jobs to dedicate themselves to the development of blogs or to be willing to accept sponsorship or another form of payment, thereby running the risk of losing their social benefits. More research is needed to understand the ways in which other kinds of knowledge and online skills shape the acquisition and performance of interactional expertise, and into the differences and similarities concerning the mediation work undertaken by this new stakeholder category across different conditions. This chapter showed how individuals diagnosed with bipolar disorder responded to pronounced tendencies toward patient engagement by developing interactional expertise and used the Internet to become highly influential, thereby turning themselves into a new stakeholder category, what I called online expert mediators. The next chapter will describe a different response to such exhortations, as it focuses on solidarity and the development of a new type of community.