Governing Habits: Treating Alcoholism in the Post‐Soviet Clinic

Governing Habits: Treating Alcoholism in the Post-Soviet Clinic. Eugene Raikhel, Ithaca, NY: Cornell University Press, 2016, 248 pp.

Eugene Raikhel’s insightful ethnography of alcoholism and its treatment regimes, Governing Habits: Treating Alcoholism in the Post-Soviet Clinic, tracks the intellectual genealogies and institutional expressions of narcology, as the medical discipline that deals with substance addiction is labeled in present-day Russia. Based on participant observation at a variety of therapeutic sites, interviews with patients and medical practitioners, and historical and archival research, Governing Habits follows the ways in which Soviet psychiatry (of which narcology was part) developed in dialogue with and under epistemological pressure from Marxist–Leninist doctrine and its commitments to materialism. Heavily indebted to the works of Ivan Pavlov on conditioned reflexes, narcology presents a fascinating reminder that what often becomes glossed as “biomedicine” is never just a singular, monolithic, or universal body of knowledge or practice, but rather a historically contingent and emergent cultural assemblage that takes different forms even when the object of its focus, on the surface at least, is the same.

Through long-term ethnographic fieldwork in St. Petersburg, Raikhel interrogates some of the controversial aspects of narcology’s clinical approaches and therapeutic tactics. The book moves through the process of “familiarizing” the apparent strangeness of narcology. In particular, Governing Habits examines Russian narcologists’ willingness to prescribe pharmaceuticals and therapeutic techniques rejected in American and European addiction medicine. The epistemological particularities of post-Soviet narcology illustrate that medical practices articulate with political cartographies and hierarchies, and that not all forms of biomedical knowledge are treated the same or have identical trajectories of circulation. But Raikhel’s argument here is more subtle. One of the book’s most important interventions is to show that while the clinical treatment of alcohol addiction in Russia (as elsewhere) often aims to refashion the self, this presupposed self is not a stable object, nor is it given a priori.

While excavating the historical trajectories and institutional assemblages of narcology, Raikhel complicates the more essentializing narratives of a passive, ideologically compliant Soviet subject (homo soveticus), while simultaneously attending to the ways in which such narratives circulate and have political efficacy. Soviet critiques of psychoanalysis as a bourgeois discipline gave rise to a distinct set of epistemic commitments that sought physiological grounds for psychological processes. Raikhel reminds us, however, that for Soviet medicine writ large, bodies and subjects were also envisioned as malleable formations. Crucially for the history of narcology, alcoholism was approached through an optic that privileged its physiological expressions over its psychological underpinnings (p. 58). Insofar as contemporary narcology still carries some of the histories of its formation, it has given rise to its own unique set of assumptions about what constitutes the self, what counts as efficacious treatment, how efficacy might be recognized in the first place, and what psychosocial and physiological processes underpin addiction.

Raikhel is attentive to the materiality of addictive substances, and Governing Habits tracks the ways in which alcohol became part of both local and national symbolic and moral economies in post-socialist Russia. The book traces how arguments about the cultural and historical centrality of vodka are harnessed locally by patients, narcologists, and other actors. But as Raikhel demonstrates, alcohol—and the ways in which it flows through and binds the textures of everyday life and sociality—is not solely a local affair. The aftermaths of the Soviet state’s biopolitical efforts to regulate alcohol consumption in the late 1980s impacted international epidemiological research. Widely understood as an example of failed policy, the prohibition campaign allowed researchers to view the collapse of the Soviet Union as a “natural experiment,” and to make claims about the relationship between alcohol consumption, social stress, and economic upheavals—subsequently cementing ideas about the unevenly distributed demographic perils of states in political and social crisis (pp. 40–41).

Governing Habits follows narcology through the sociopolitical upheavals of the 1990s and early 2000s, a time when the Russian health care system underwent a radical and somewhat chaotic transition from the nationalized universal health care championed by the Soviet Union to a mixed system of public and private health care financially buttressed by a dual insurance structure, one mandatory and one voluntary (p. 84). This was also the period when narcology underwent a crisis of legitimacy. No longer authorized by the state to conduct some of its more forceful interventions, such as involuntary treatment, narcology had to reinvent itself in the midst of the complicated tangle of free and paid services. Despite its crisis of legitimacy, narcology landed on the private medicine side of the equation, and it became one of the more profitable branches of medical practice. Narcology thus offers a case study of the ways in which the Russian medical system is organized, at the intersection of markets and state projects of population management (Chapter 3).

By the time of Raikhel’s fieldwork, narcology found itself in the company of strange bedfellows. In the midst of the efflorescence of occult services and faith healing during the first decade of post-socialism, both the therapeutic logics and techniques deployed by narcologists and the assumptions about efficacy articulated by patients drew heavily on the idioms of personal charisma and belief, isomorphic to those of charismatic healers, who had entered Russia’s therapeutic markets in the 1990s (Chapter 4). In analyzing the deployments of seemingly unusual interventions like disulfiram treatment (knimzashchita) and coding (kodirovanie), which harness the placebo effect while opening it to critical reframing as itself a historically emergent category, Raikhel’s argument moves along two parallel lines. On the one hand, it interrogates the ways in which narcology offers a glimpse into a distinct set of post-socialist “technologies of the self.” On the other, it expands our understanding of how efficacy and uncertainty operate in clinical practice, and how they come to be recognized at the intersections between clinicians’ tactics, scientific discourses, and patient experiences.

Raikhel situates the efforts of post-socialist narcologists against historically complex, entangled, and emergent notions of the self and its management. The final chapter turns to the circulation of the Alcoholics Anonymous 12-step program into Russia, showing the complex social textures that bracket the program’s aspirations to unproblematic translocation and its openness to abstraction from its loci of origin (Chapter 5). Raikhel shows how seemingly global therapeutic discourses and techniques are, in fact, densely social formations. Introducing the concept of “illness sodality,” which he borrows from the work of Robert Lowie, Raikhel seeks to go beyond a standard Foucaultian reading of the confessional technologies of self-governance that accompany addiction treatment, in Russia and elsewhere. In this, the book’s intervention decouples the formation of illness-centered collectivities from the projected personae and patient identities these collectivities presuppose and cultivate. Instead, Raikhel shows how different bundles of techniques and discourses can circulate somewhat independently of each other, while remaining grounded in concrete social relations and networks.

Governing Habits is an eminently accessible book. Interspersed with illustrative ethnographic vignettes, it strategically centers Russian patients’ and clinicians’ voices. Its theoretical interventions and historical rigor will offer a useful resource for scholars of medical anthropology and social studies of science and technology. Its rich ethnographic engagements also make it suitable for teaching students interested in these topics, as well as for adoption in courses on post-socialism, Russia, and Eastern Europe.

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