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Russianmodernisation.fiCult Med Psychiatry (2010) 34:132–168DOI 10.1007/s11013-009-9163-1 Post-Soviet Placebos: Epistemology and Authorityin Russian Treatments for Alcoholism Published online: 5 December 2009 ! Springer Science+Business Media, LLC 2009 The dominant modalities of treatment for alcoholism in Russia are suggestion-based methods developed by narcology—the subspecialty of Russianpsychiatry which deals with addiction. A particularly popular method is the use ofdisulfiram—an alcohol antagonist—for which narcologists commonly substituteneutral substances. Drawing on 14 months of fieldwork at narcological clinics inSt. Petersburg, this article examines the epistemological and institutional conditionswhich facilitate this practice of ‘‘placebo therapy.'' I argue that narcologists'embrace of such treatments has been shaped by a clinical style of reasoning specificto a Soviet and post-Soviet psychiatry, itself the product of contested Soviet politicsover the knowledge of the mind and brain. This style of reasoning has facilitatednarcologists' understanding of disulfiram as a behavioral, rather than a pharmaco-logical, treatment and has disposed them to amplify patients' responses throughattention to the performative aspects of the clinical encounter and through man-agement of the treatment's broader reputation as an effective therapy. Moreover,such therapies have generally depended upon, and helped to reinforce, clinicalencounters premised on a steeply hierarchical physician–patient relationship.
Alcoholism ! Substance dependence treatment ! Addiction medicine ! Placebo ! Pharmaceuticals ! Russian psychiatry During Russia's period of intense social ferment over the 1990s and early 2000s,rates of alcohol dependence and alcohol-related harm increased substantially, at the E. Raikhel (&)Department of Comparative Human Development, University of Chicago, 5730 South WoodlawnAvenue, Chicago, IL 60637, USAe-mail: [email protected] Cult Med Psychiatry (2010) 34:132–168 same time that mortality rose sharply and male life expectancy droppedprecipitously (Leon et al. ; Nemtsov ; Notzon et al. Whilethe precise mechanisms have been widely debated, epidemiologists and publichealth researchers generally agree that alcohol consumption, abuse and dependencecontributed greatly to these alarming health outcomes (Demin and Demina ;Cockerham Field and Twigg Dmitrieva et al. ). What is more,while these epidemiological changes were taking place, the Russian state waswithdrawing from the interventionist public health role which the Soviet Union hadplayed in governing alcohol and its consumption.1 One effect of this withdrawal wasto render alcoholism, previously treated as a social disease, increasingly individ-ualized and medicalized by default. Thus even while biomedical explanations ofheavy alcohol consumption remain unpopular among many laypeople in Russia,medical (and quasi-medical) treatments have gained significance as the primarymeans by which alcoholism is governed.2 A particularly popular and prevalent mode of treatment is the use of injected or implanted depot disulfiram—an alcohol antagonist—which narcologists (as spe-cialists in addiction medicine are known in Russia) commonly substitute withchemically neutral substances. While narcologists represent this therapy to patientsas khimzashchita (which literally translates as ‘‘chemical protection'')—a potentpharmacological treatment which renders their bodies unable to process alcohol—privately they often describe the method as ‘‘placebo therapy'' and emphasize itsreliance on mechanisms of suggestion (vnushenie). Such clinical techniques havebeen used in Russia since the 1950s, and according to some sources, khimzashchitaand closely related methods currently make up the majority of long-terminterventions for alcoholism offered by narcologists (Ivanets ; Sofronov; Mendelevich ).3 Such therapies are also highly contested in Russia: condemned on a variety of clinical, ethical, and political grounds. They are criticized by proponents of TwelveStep therapies for ignoring the underlying emotional and spiritual roots ofalcoholism and by advocates of harm reduction for being falsely represented as‘‘cures'' for a chronic disease (Mendelevich Even many clinicians whoadminister khimzashchita point out that, while it is often successful in facilitatingshort-term remissions, patients rarely see the need to supplement it with longer-termpsychosocial interventions—leading to a cycle of decreasingly successful and 1 The final and most notable intervention was the antialcohol campaign which ran during the first half ofMikhail Gorbachev's tenure as General Secretary, from May 1985 into 1988, and was characterized by aprohibitionist stance on alcohol consumption (White Reitan ).
2 Illicit drugs, on the other hand, have been the object of increasingly stringent state policies and well-funded interventions in Russia since the early 2000s. Most of this activity has focused on opiates and hastaken a criminalizing/law enforcement approach, particularly since the inception of the Federal DrugControl Agency in 2003 (Orlova ).
3 Mendelevich ) reports the results of a survey showing that such methods ‘‘constitute up to 80% ofall treatment methods offered by official and unofficial Russian narcology.'' While I did not conduct asystematic survey, a range of related suggestion-based methods—including disulfiram, coding,emotional-stress psychotherapy, neurolinguistic programming (NLP), Eriksonian hypnosis and subliminalsuggestion—made up the vast majority of treatments offered at governmental and commercial clinics Ivisited.
Cult Med Psychiatry (2010) 34:132–168 increasingly short remissions (Valentik , p. 244; Sofronov Notsurprisingly critiques made by visiting Western European and North Americanphysicians have often focused on the disregard which such treatments seem to showfor a normative model of patient autonomy; instead of treating patients asautonomous, rational and (potentially) self-knowing individuals, these methods aresaid to rely on ‘‘people's ignorance'' and their ‘‘belief'' to frighten them intosobriety (Fleming et al. ; Finn Parfitt ). According to such accounts,the mechanism underlying khimzashchita is very simple; it consists of the physicianconvincingly telling his patient, ‘‘If you drink—you die'' (Chepurnaya and Etkind, par. 2).
In this article, I draw on historical and ethnographic research to examine why, despite such critiques, khimzashchita remains a popular form of treatment amongphysicians and patients in contemporary Russia. In particular, I trace how disulfiramtreatment in Russia has been shaped by a clinical style of reasoning specific to aSoviet and post-Soviet professional ethnopsychiatry, itself the product of contestedSoviet intellectual and institutional politics over the knowledge of the mind andbrain.4 I argue that this style of reasoning has facilitated narcologists' understandingof disulfiram as a behavioral, rather than a pharmacological, treatment and hasdisposed them to amplify patients' responses through attention to the performativeaspects of the clinical encounter as well as through management of khimzashchita'sbroader reputation as an effective therapy. Moreover, I suggest that, with a fewexceptions, such therapies have depended on, and helped to reinforce, clinicalencounters premised on a steeply hierarchical physician–patient relationship.
Over the past two decades medical anthropologists have increasingly drawn attention to the circulation and meaning of medicines, and their articulation withvarious lay and professional models of causation, idioms of distress, healingsystems and local understandings of efficacy, as well as their place in globalpolitical economies of health (van der Geest and Whyte ; Etkin ; Whyteet al. Petryna et al. ). This focus on medicines has been particularlysignificant for scholars who have traced how the biologization of psychiatry has—along with the neoliberal transformation of health care in many countries—facilitated a growing emphasis on pharmaceutical interventions for mental illnesses(Healy ; Shorter ; Luhrmann ; Biehl ; Lakoff ; Rose While alcoholism and addiction have resisted subsumption under the aegis ofbiomedicine or psychiatry for much longer—at least in the English-speaking world(Valverde recent years there has been great excitement in somequarters of the medical community about pharmacological treatments for addiction,including drugs which dampen the neurochemical effects of opiates or alcohol andthose which reduce sensations of craving (Valverde ; O'Brien Lovell; Vrecko ).
4 Throughout this article, I use the notion of ‘‘style of reasoning'' drawn from the work of Fleck() by Hacking (and further elaborated by Young , ). A style of reasoning,Young ) writes, ‘‘is composed of ideas, practices, raw materials, technologies and objects.… It is acharacteristically self-authenticating way of making facts, in that it generates its own truth conditions''(p. 158).
Cult Med Psychiatry (2010) 34:132–168 Surveying these developments Nikolas Rose and other social scientists have argued that as neurobiological ways of thinking about and acting on human beingsdiffuse beyond the laboratory, a somatic understanding of the self is increasinglydisplacing the psychological or identity-based subject of the twentieth-century(Rose Vrecko , This ‘‘neurochemical personhood'' is linkedby Rose to a characteristically neoliberal way of governing pathological behaviorand—in the case of addiction—desire. The new norm is not just the self-maximizingindividual but one who internalizes functions once carried out by a sovereign stateor social institutions, assuming responsibility for the management of his or her ownsusceptibilities and desires (Rose ).
However, as anthropologists and historians have shown, there is reason to be skeptical of arguments which ascribe such an epochal and unidirectional shift inpersonhood and self-governance to neuroscience and psychiatry.5 At the very least,it is clear that psychiatry's diagnostic categories and modes of treatment arequestioned and contested, or subtly transformed, as they move from experimental toclinical settings or from one cultural setting to another (Kleinman ; Gaines; Lee ; Skultans ; Lakoff ; Schull ; Lloyd ; Kitanaka; Saris ). A clear-cut narrative of the rise of the ‘‘somatic self'' is alsoundercut by accounts examining the mind/brain distinctions and constructions ofpersonhood underlying various professional ethnopsychiatries (Gaines ;Young Miresco and Kirmayer ). The Russian practice of khimzashchitais particularly significant to these debates because it so clearly calls into question anumber of distinctions which prevail in North American clinical practice, as well asin much of the social science literature: not only the distinction between the somaticand the psychological, but also that between pharmacology and psychotherapy, andbetween medication and placebo.
The article is organized as follows: after a brief description of my research methods and St. Petersburg's Addiction Hospital as a fieldwork setting, I present thecase of a patient receiving disulfiram treatment at the hospital. To explore theparticularities of this treatment modality I draw on the English-language medicalliterature on disulfiram. I then examine how disulfiram was taken up in the SovietUnion, tracing the development of a neurophysiological style of reasoning in Sovietpsychiatry and its application to treatments for alcoholism. In the following sectionsI describe the clinical use of khimzashchita, examining both physicians' andpatients' conceptions of the treatment. Finally I examine how the treatment has bothdepended on and reinforced hierarchy in the doctor–patient relationship and discusshow this has changed in the transition to the post-Soviet political and economicorder. The article ends with a consideration of the implications of the case ofkhimzashchita for the anthropology of psychiatry.
5 Others have questioned the supposed novelty of the ‘‘somatic self.'' As Nancy Campbell notes,in describing the broad popularity of psychotropic medications in North America from the late 1950sonward, ‘‘We have been ‘becoming neurochemical selves' for a long time'' (p. 247, n. 3).
Cult Med Psychiatry (2010) 34:132–168 Research Methods and Ethnographic Setting This article is based on 14 months of fieldwork at a number of addiction treatmentfacilities in St. Petersburg, Russia, conducted between 2002 and 2004. The bulk ofthe material presented here was specifically drawn from interviews and observationsconducted at the municipal Narcological Service. These include 30 interviews withpatients and 24 with physicians in the service, as well as numerous informalinteractions and conversations. In addition to the Narcological Service, I conductedfieldwork at one commercial addiction clinic and a charitable Twelve Step-basedrehabilitation center, where I also spoke to physicians, counselors, and patientsabout their experiences with khimzashchita and similar treatment modalities. I alsointerviewed several narcologists and psychiatrists in private practice, sat in on aseries of training lectures on narcology for physicians, attended open sessions ofAlcoholics Anonymous and observed se´ances conducted by a self-proclaimed‘‘Orthodox psychotherapist.'' Finally, I conducted extensive textual research in theRussian-language scientific and medical literature on addiction and its treatment.
Throughout the article, I employ such textual sources to situate current clinicaltechnologies in relation to the categories and styles of reasoning prevalent in Sovietpsychiatry and narcology.
The project was approved by the Institutional Review Board of my home institution at the time (Princeton University) as well as by the St. PetersburgDepartment of Public Health. In order to ensure the confidentiality of informants, allof the patients and physicians whom I interviewed at the Narcological Service havebeen given pseudonyms or general appellations (i.e., ‘‘older narcologist''), and someidentifying details have been changed.6 While I refer to physicians who have madetheir views known in previous publications by their real names (AlexanderSofronov), I do not ascribe to these physicians any statements substantively beyondthose they have already made in print.
During the time this research was being carried out, St. Petersburg's Narcological Service consisted of dispensaries in each of the city's administrative districts(raiony) and a central 500-bed Municipal Addiction Hospital (Gorodskaianarkologicheskaia bol'nitsa) to which patients were sent for hospitalization. Whilemany aspects of addiction treatment in Russia had been radically transformedduring the 1990s, the overall structure of the state-funded network had not changedsignificantly since the 1970s when the Soviet narcological system was established.
This Soviet system had been a hybrid, made up of both medical institutions run bythe Ministry of Health and penal/therapeutic ones administered by the Ministry ofInternal Affairs, the seat of Soviet police organs. While these institutions wereinstantiations of distinct disciplinary and professional ideologies about the nature,etiology and appropriate treatments of alcoholism, the notion of alcoholism as a 6 To demarcate the roles of different informants, I have used first names (such as Vyacheslav, Pavel, orSasha) to indicate patients and Twelve Step counselors and first names along with patronymics (e.g.,Anton Denisovich, Alexander Sergeevich) to mark most physicians. The first name/patronymiccombination is a relatively formal type of address typically used to mark respect or social distance inRussian. While running the risk of essentializing the distinction between physicians and patients, thisnaming system gives a sense of the interpersonal hierarchy in play at most St. Petersburg clinics.
Cult Med Psychiatry (2010) 34:132–168 problem of public order saturated the entire system (Beliaev and Lezhepetsova; Solomon Babayan and Gonopolsky ; Segal Noncriminalalcoholics and those who resisted the ‘‘compulsory treatment'' (prinuditel'noelechenie) at hospitals and clinics could be committed for 1–2 years in explicitlypenal institutions called Therapeutic-Labor Profilactories (LTPs; Lechebno-trud-ovye profilaktorii), which were modeled on labor colonies and prison camps(Tkachevskii p. 39; Sytinsky and Gurevitch Beginning in the late1970s, the narcological system grew rapidly, reaching its peak of funding and accessto resources during the final Soviet antialcohol campaign in 1985–1988.
By the time of my first visit to the hospital in 2003, certain elements of the narcological system had changed profoundly, while others reflected a strikingcontinuity with the Soviet period. Shortly after the fall of the Soviet Union, theRussian Federation had moved to dismantle the explicitly punitive elements of thesystem. LTPs were formally disbanded in 1994, the same year that involuntaryhospitalization for noncriminal alcoholics was outlawed (White Entin et al.
; Gilinsky and Zobnev ). Physicians at the hospital recounted how,throughout the 1990s and early 2000s, they had struggled to manage the increasingnumbers of alcoholic patients as well as the sudden rise in injected heroin use(which was accompanied by a rapid spread of HIV infection) (Heimer et al. ;Leon et al. These efforts were made all the more difficult by the severe budgetary cutbacks the system experienced in connection with the dismantling of the Soviet-administered economy generally and the restructuring of the health-care sector inparticular (Egorov Twigg ). This meant that, while basic treatmentremained free of charge, the hospital had begun to charge for various additionalservices. Shortages of medications and staff were also common. Physicians oftencomplained of having to spend over half their time on paperwork because theylacked computers or administrative support.
Vyacheslav and the Torpedo: Cycles of Treatment While interviewing patients at the Addiction Hospital, I met Vyacheslav, a portlyfactory worker in his fifties. He was, in some ways, a typical patient, although,unlike many others, he lived in a communal apartment with his wife. Since thehospital was one of the only institutions in the city which offered detoxification andtreatment free of charge, it attracted many patients who had lost their homes andmeans of employment; at least half of the patients on most wards were homeless. Aswe sat in a small examination room, Vyacheslav told me that his son had died in thearmy 6 years earlier; recently his daughter had given birth to her own children.
Vyacheslav gestured toward his motivation for sobriety in describing his newfamilial role: ‘‘I'm already a grandfather, but still I continue to drink.'' He describedhis stay at the hospital as part of a yearly cycle. Each year he would go on a drinkingbinge (zapoi), at the end of which he would be persuaded by his wife to return to thehospital.
Cult Med Psychiatry (2010) 34:132–168 Like other patients arriving at the hospital, Vyacheslav was typically treated for a period of 1 month. Most of the hospital's nine wards rely on treatment protocolssimilar to those used during the Soviet period (Fleming et al. ). Detoxificationtakes place with the aid of intravenously delivered vitamins as well as a heavypharmacological regimen, including the liberal use of tranquilizers and antipsy-chotics (Fleming ; Ivanets Following the completion of detoxificationand prior to his discharge from the hospital, Vyacheslav received an injection(colloquially known as a torpedo) which, he was told, would keep disulfiram in hisbloodstream over the course of a year. Fearing the negative effects of drinking withthe substance in his body, Vyacheslav explained that he always waited until thecourse of the torpedo was over before embarking on another binge. Once, he hadtried another procedure: the physicians had implanted a capsule under his skinwhich was said to slowly release disulfiram for five years. That time Vyacheslavhadn't been able to wait it out: ‘‘I didn't drink for two and a half years. Then I paidthem and had the implant removed (rasshilsia). That's it.'' Typically this cycle repeated itself every year, he explained, without excessive regret or concern. Of his wife, Vyacheslav explained, ‘‘When I'm drunk we don'thave any quarrels. She understands that even if I'm drunk every single day, even fora month, that eventually I'll come to and say, ‘Let's go to Vassilievskii.'7 Sheunderstands that if she tried to push me it will just be harder on the nerves.'' Whilehe felt that abstaining from alcohol noticeably dampened his social life, Vyacheslavalso argued that he and his family had successfully learned to manage his tendencyto indulge in drink.
Vyacheslav's description of khimzashchita as a physiologically based treatment closely resembled its depictions by physicians in conversations with patients and in(nonspecialist) publications and advertisements. ‘‘There's also a special injectionthey can give you in your vein,'' he explained, adding, with a clear deference to theauthority of medical professionals: ‘‘It's all figured out by the professors so that itgradually dissolves. And the capsules: they get stuck to something inside you andalso gradually dissolve.'' Yet, as narcologists explained to me (sometimesreluctantly), it is common practice to inject or implant patients with neutralsubstances (often vitamins or saline) in place of disulfiram. Moreover, asnarcologists saw it, whether or not active disulfiram is used, khimzashchita reliesheavily on suggestion and has more in common with hypnosis therapies than withneurochemically based interventions.
Indeed when I brought up khimzashchita in my conversations with narcologists, some initially represented it as a pharmacological treatment, while others depicted itas ‘‘psychotherapy.'' Irina Valentinovna, a narcologist on the acute ward of theAddiction Hospital explained it this way: Khimzashchita is a psychotherapeutic method. In principle, we give aregular—you can give a placebo—this depends on the personality of thepatient—and either we use a placebo or the chemical…. I give you thismedication. I give you a prohibition [zapret] through personal psychotherapy 7 The Addiction Hospital is located on Vasilievskii Island, one of the main islands of centralSt. Petersburg.
Cult Med Psychiatry (2010) 34:132–168 [lichnostnaia psikhoterapiia]: for a certain period of time you don't have theright to consume alcohol [spirtnoe]. If he waits through the period, then we doanother one. His self-image rises.
While it was clear that khimzashchita was meant to help facilitate what narcologists called periods of ‘‘remission'' (sobriety) for patients, it seemed, basedon Irina Valentinovna's description, that the chemical content of the medication(disulfiram or ‘‘placebo'') mattered less than the meanings enacted by thenarcologist and her clinical tools. I found myself both troubled by the deceptionseemingly entailed by this blithe equation of ‘‘placebo'' with disulfiram andfascinated by the questions it raised. Was khimzashchita a somatic or apsychological treatment? More importantly, why did this distinction seem to matterso little to the narcologists I spoke to? To answer these questions, it important tofirst review the medical literature on disulfiram treatment and to examine how thistherapy was taken up in the Soviet Union.
Disulfiram Treatment: Nonspecific Pharmacology While the literature on placebo phenomena shows clearly that all medicationsinduce both specific and nonspecific effects—as well as interactions between theseeffects—disulfiram's mode of therapeutic action makes these interactions partic-ularly clear (Price et al. Often referred to in Russia as teturam, Esperal, orAntabuse,8 disulfiram prevents the body from fully processing alcohol. By blockingthe action of aldehyde dehydrogenase, a key enzyme in the metabolic pathway ofethanol, the drug causes a buildup of the toxic by-product acetaldehyde, withextremely unpleasant consequences for patients. Rather than the pleasurable effectsof alcohol intoxication, people with active disulfiram in their bodies experienceflushing, nausea and high blood pressure soon after drinking—referred to in themedical literature as a disulfiram–ethanol reaction (DER) (Eneanya et al. ;Kenna et al. ; Mann ). Thus as the authors of one review explain, ‘‘Whentaken in an adequate dose, disulfiram usually deters the drinking of alcohol by thethreat or experience of an unpleasant reaction'' (Brewer et al. , p. 329;emphasis added). Often recommended as an adjunct to psychosocial treatmentprograms, disulfiram is used to facilitate periods of sobriety during which patientscan develop a ‘‘sober life-style'' (p. 329).
While it is often portrayed as the first pharmacological treatment for alcoholism to have been developed, the mechanism underlying disulfiram's effects has beendescribed and classified in several significantly different ways, and these accountsare linked to specific clinical uses of the drug. Researchers framing disulfiram as apharmacological—rather than a behavioral—treatment (particularly its earlyproponents) often described it as a ‘‘sensitizing'' drug (e.g., Hald and Jacobsen 8 Derived from the full chemical name—tetraethylthiuram disulfide—teturam or tiuram are names usedfor disulfiram in Russian (Sereiskii ; Eneanya et al. ). Antabuse is the trademarked name ofdisulfiram. Esperal is a brand name for disulfiram produced by the French pharmaceutical companySanofi-Aventis, but in Russia ‘‘Esperal''' typically refers specifically to disulfiram implants.
Cult Med Psychiatry (2010) 34:132–168 ; Martensen-Larsen ; Ivanets Conversely, contemporary research-ers argue that, unlike more recently developed pharmacological treatments foralcoholism, such as naltrexone and acamprosate, the efficacy of which is based on aneurochemical dampening of patients' craving, the effects of disulfiram arepsychologically mediated (Kenna et al. ).
However, even the specific mechanism underlying this psychological mediation has been described in various ways, ranging from ‘‘aversion'' to ‘‘stress'' to‘‘suggestion.'' Again, these explanations reference distinct clinical applications. Forexample, disulfiram treatment was first conceived of as a form of aversion therapy:‘‘tests'' or demonstrations of its effects were carried out on patients who were givendoses of ethanol to drink shortly after consuming the drug (Suh et al. As Iargue below, this link to aversion therapy is important in understanding the roledisulfiram has played in Russian alcoholism treatment. While some researchers stillargue that disulfiram is meant to ‘‘create an aversion to alcohol, rather thanmodulate its neurochemical effects'' (Mann p. 489), others emphasize that ithas immediate effects on behavior ‘‘by replacing delayed with immediate negativeconsequences'' (Heather p. 471). In either case, we can conclude that it is apatient's anticipation or memory—whether conscious, unconscious or bodily—ofan unpleasant or frightening experience which is meant to change his or herbehavior.
Over the past 70 years disulfiram has played divergent roles in the public health and medical systems of various countries, reflecting differences in ethnopsychiatricmodels of alcohol dependence, institutional and political economic conditions andnotions about individual volition and personal responsibility (Chick and Brewer). For example, while it continues to serve as the cornerstone of alcoholismtreatment in Denmark, the prevalence of its use in North America has long sincewaned (White ; Steffen Although many studies have shown disulfiramtherapy to be a potentially effective means of increasing the lengths of patients'remissions, adherence represents the major obstacle to efficacy (Fuller and Gordis; Suh et al. ). Once ingested, the medication remains at chemically activelevels for only several days, which means that patients must take the drug regularlyfor the threat of an adverse reaction to alcohol to remain (Eneanya et al. ;Brewer et al. :331). While this may not represent a problem for highlymotivated patients, for many others the challenge of adhering to this treatment is asgreat as that of abstaining from alcohol itself (Valverde , p. 99; Steffen p. 180). Not surprisingly, disulfiram therapy seems to be most effective when arelative or clinician is able to monitor or supervise the patient's consumption of themedication (Brewer et al. ; Fuller and Gordis ). The issue of compliancehas also been addressed by embedding disulfiram treatment into a number ofinstitutional structures and coupling it with behavioral technologies in whichpatients' agency is closely delimited or curtailed—such as parole, probation ordispensation of the drug at specialized clinics (O'Farrell et al. ; White p. 227; Brewer et al. , pp. 332–336; Steffen For this reason the treatmentis depicted by critics as one which requires an unacceptable level of coercion orsocial control (Steffen , pp. 184–185).
Cult Med Psychiatry (2010) 34:132–168 In a different attempt to manage this problem of treatment adherence, the method of implanting capsules of disulfiram subcutaneously was developed in France duringthe 1950s (Kline and Kingstone ; White , p. 228). Here agency foradherence was shifted from either the patient or his or her caretaker and structuredinto the implant, which was meant to gradually release the chemical into thebloodstream. However, numerous clinical studies have shown that commerciallyavailable implants release detectable levels of disulfiram into the patient'sbloodstream for only a short period of time (Johnsen and Morland ; Breweret al. In other words, after the first week following the implantation of thedisulfiram, patients are highly unlikely to suffer from a DER. At the same time,since the early 1970s, researchers studying disulfiram implants have noted theireffectiveness relative to unsupervised oral disulfiram, and most have agreed thatsuch effects were due to a ‘‘psychological rather than a pharmacological deterrent''(Malcolm et al. , p 488; Kline and Kingstone ). The authors of one reviewsummarize the clinical findings on implants this way: ‘‘All pharmacologicaltreatments have nonspecific or placebo effects as well as pharmacological effects.
Disulfiram is no exception'' (Brewer et al. p. 331).
As a pharmacological therapy which seems to work primarily by nonpharma- cological means, disulfiram occupies an uneasy position in the biomedical literatureand clinical practice. With a few exceptions, most researchers writing in theEnglish-language literature refer to disulfiram as having ‘‘nonspecific or placeboeffects'' with some trepidation, or as evidence for its overall ineffectiveness. In part,this has to do with the deeply ambivalent attitude which most of biomedicine hastaken toward treatment outcomes which are not attributable to a specific materialcause, as well as to the subjective dimensions of human experience (Kirmayer ;Thompson et al. ).
Anne Harrington has argued that the roots of twentieth-century skepticism toward placebos emerged when epistemological concerns regarding the existence ofinvisible forces such as ‘‘animal magnetism,'' intertwined with moral anxietiesprovoked by the notion of ‘‘a weak and impressionable mind (i.e., the patient's)[coming] under the thrall of a strong and persuasive personality [i.e., the doctor's orhealer's]'' (Harrington , p. 185, ). Harrington argues that theseepistemological and moral anxieties were brought together in the nineteenth-centuryconcept of ‘‘suggestion''—‘‘the ‘capacity to transform an idea directly andautomatically into a sensation or movement''' (185). Soon thereafter, with the riseof drug-based therapies during the early to mid-twentieth-century, the practice ofgiving patients chemically neutral pills became increasingly viewed by medicalopinion as a sham at worst and as an intervention with no physiological basis used tomollify ‘‘difficult'' patients at best (Harrington ).9 In the case of disulfiram, this 9 In addition to these epistemological issues, the role of placebos at the center of the clinical trialapparatus poses an additional methodological challenge for the investigation of treatments which mayhave largely nonspecific effects. Even when researchers acknowledge the relative effectiveness ofdisulfiram, they often find themselves bound by an inability to demonstrate this effectiveness according tothe dictates of their professional and institutional criteria: ‘‘Since it is the psychological deterrent effect of[disulfiram] rather than its biological effect that is useful, it is difficult to envisage how its efficacy couldbe demonstrated in a classical double-blind, placebo-controlled trial'' (Mann p. 489).
Cult Med Psychiatry (2010) 34:132–168 epistemological ambiguity is compounded by the fact that, unlike placebo analgesiaor changes mediated by the immune system, the locus of disulfiram's ‘‘nonspecific''effect is particularly unclear. Sobriety which results from disulfiram therapy is achange in behavior which can be conceptualized as mediated by both conscious andunconscious mental processes.10 While clinical phenomena, variously described as ‘‘suggestion,'' ‘‘placebo,'' or ‘‘nonspecific effects,'' have long posed an epistemological challenge for asomatically grounded biomedicine, many of the narcologists I spoke to in St.
Petersburg emphasized precisely these aspects of disulfiram treatment. Narcologistslike Irina Valentinovna explicitly described khimzashchita as ‘‘placebo therapy'' oras a treatment which depends on mechanisms of suggestion (vnushenie). As onephysician working in a commercial addiction clinic put it, ‘‘In addition to the purelychemical effect [of disulfiram], there is a suggestive effect [effekt vnushenia].'' Whywere narcologists seemingly less troubled by the epistemological problems posed byplacebo therapy than many of their Western European and North American peers? Isuggest that we cannot answer this question without examining khimzashchita as aproduct of Soviet narcology's neurophysiological logic and a particular clinicalstyle of reasoning. Indeed, I argue that narcologists' clinical reasoning is shaped, atleast in part, by a Russian/Soviet genealogy of ideas about suggestion and healingwhich is radically different from its counterpart in the English-speaking world.
A Logic of Reflexes: Suggestion in the Soviet Sciences of the Mind and Brain While narcology was only developed as a distinct subspecialty during the 1970s,many of its therapeutic methods and styles of thought were developed much earlier,under the aegis of Soviet psychiatry. Along with other sciences of the mind andbrain in the Soviet Union, psychiatry had been deeply affected by the politicallyshaped dominance of Pavlov's theory of ‘‘higher nervous activity.'' During the earlySoviet period, the relationship between physiology and psychology was anextremely contentious ideological issue, primarily because it represented a sphereof knowledge in which Marxists hoped to link their understanding of human beingsas historical actors with an objective science of humans as material beings (Joravsky; Smith p. 191). This was largely approached through the concepts ofdialectical materialism. In this context Pavlov's reflex theory was not simply anexample of a concrete behavioral mechanism, but a way of conceptualizing the‘‘dialectical'' relationship between human biology and the environment (Graham 10 Because the intended effects of khimzashchita are behavioral (abstinence) rather than physiological,some readers of previous versions of this article have asked whether it is appropriate to call it ‘‘placebotherapy.'' In this paper, khimzashchita is discussed as a placebo or suggestion-based therapy becausethese were the terms used by narcologists in St. Petersburg. Additionally, it is worth noting that Sovietpsychiatry's interpretation of both placebo effects and hypnotic suggestion through the framework ofconditioned reflexes blurred distinctions between behavioral and physiological effects. Of course, allclinical interventions also shape behavior through the way in which they are prescribed and dispensed orthrough the institutional arrangements within which they are embedded. Indeed, Saris ) has arguedthat such a transformation of behavior is the primary aim of another putatively pharmacological treatmentfor addiction—namely, methadone maintenance therapy (pp. 260–261).
Cult Med Psychiatry (2010) 34:132–168 , p. 163; Joravsky ; Petryna , p. 162). In practice, however, this mayhave often meant a reduction of psychology to physiology, of mind to brain—ormore precisely—of personhood to reflex action.
The ascendance of Pavlovian theory in the Soviet sciences of the mind and brain began after a brief period of revolutionary utopianism during the early 1920s when avariety of approaches and schools—including psychoanalysis—coexisted. Duringthe period known as the Great Break (marked by the start of massive industrial-ization projects and the collectivization of agriculture in the late 1920s), Stalin andother Party leaders sharply departed from an earlier conciliatory policy towardprofessionals and initiated a program of cultural revolution intended to create a newclass of Soviet (nonbourgeois) specialists whose orientation was meant to coincidewith those of the party-state (Fitzpatrick ). This cardinal turn in policy set thestage for the creation of a Soviet psychiatry which would, in its broad contours,persist at least until the late 1980s (Calloway Skultans Psychoanalysis as well as various Russian psychological schools were increasinglycondemned as ‘‘idealist,'' while Pavlov's reflex theory was promoted in increasinglyforceful terms (Todes Etkind ; Miller ). This movement culminatedafter WWII in a series of conferences on physiology, psychiatry and psychology(held between 1950 and 1952) at which Pavlov's doctrine was enshrined into thepantheon of Soviet socialism as an objective foundation for the sciences of the mindand brain (Joravsky , p. 413; Windholz While the post-Stalin period sawa resurgence of interest in psychology and theories of consciousness, the influenceof the now-officialized Pavlovian doctrine on clinical psychiatry extended well pastthis period, in part due to the prominent institutional posts held by its adherents, inpart to the persistence of treatments which had been developed during that periodand in part to the ways it shaped subsequent disciplinary assumptions and styles ofthinking in psychiatry (Segal ; cf. Fleck p. 20).
One commonly overlooked consequence of the dominance of Pavlov's theories was the legitimacy it accorded to practices of suggestion, hypnosis and, lessdirectly, placebo therapy, by reframing them in entirely physiological terms(Chertok p. 11). In elaborating his theory of higher nervous activity, Pavlovrelied on the notions of excitation, inhibition and equilibrium to describe basicprocesses taking place in the nervous system, which he correlated with experimentalevidence produced through conditioning. For Pavlov, inhibition encompassed allprocesses which weakened conditioned reflexes, and was distinguishable into thecategories of ‘‘external inhibition,'' ‘‘internal inhibition'' and the inhibitionassociated with sleep (Smith pp. 200–201). Pavlov described hypnosis as atransitory state which resulted when the inhibitory process that led to sleep occurredto a less extensive degree (Platonov ; Pavlov p. 84). Further, heargued that ‘‘suggestion in hypnosis can be rightly interpreted as such a phase ofinhibition when weak conditioned stimuli (words) produce a greater effect than theevidently stronger and real external stimuli'' (p. 85). In other words, hypnosis wasunderstood as a state of consciousness which facilitated suggestibility.
This account helped to render hypnosis scientifically legitimate by placing it firmly in the realm of the material, allowing it to be incorporated into mainstreampsychiatry (Slobodianik Hoskovec Babayan and Shashina p. 99).
Cult Med Psychiatry (2010) 34:132–168 Pavlov's theories also led to the development of various clinical interventions whichwere generally categorized as ‘‘psychotherapy.''11 This clinical application ofhypnosis emerged partly from the theory itself: for Pavlov sleep and hypnosis wereforms of inhibition which were ‘‘protective''—a notion which also facilitated thewidespread use of sleep therapy in Soviet psychiatry (Wortis p. 161).
Of course it is difficult, if not impossible, to ascertain whether clinicians of the time used suggestion-based therapies because they actually thought of them indialectical terms. It seems just as likely that practicing clinicians were willing toemploy techniques such as hypnosis and placebo therapy precisely because they didnot conceptualize them as ‘‘mind'' acting on ‘‘body,'' but simply as ‘‘body'' actingon ‘‘body.'' For these physicians, physiology may have been a sphere of explanationwhich extended to, and subsumed (or somaticized), ‘‘mind,'' thus rendering mootthe seeming paradox of hypnosis. In either case, a conception of human biologywhich was undoubtedly ideological also had practical consequences for clinicians inthat it rendered suggestion and placebo effects thinkable.
Moreover, once therapeutic methods based on these effects received official sanction, they arguably became part of an institutional logic generally immune tosuch epistemological concerns. Thus with a few notable exceptions and a paralleltradition of rational psychotherapy, the majority of techniques framed as ‘‘psycho-therapy'' during the Soviet period employed mechanisms of hypnosis andsuggestion (Wortis p. 88; Kirman Segal Lauterbach ;Etkind b). By the 1970s, these methods encompassed a range of techniques,including individual and group hypnosis, more and less directive forms ofsuggestion, as well as ‘‘direct suggestion,'' in which the patient remains in a wakingstate, ‘‘indirect suggestion'' (which included the use of placebos) and techniques ofautosuggestion (Lauterbach , p. 81).
Somatic Suggestions The Danish developers of disulfiram therapy had initially employed it as a form ofaversion therapy, and this style of treatment fell on particularly fertile ground in theSoviet Union (Hald and Jacobsen ; Martensen-Larsen ). During the late1940s, when Soviet medical researchers first began to experiment with disulfiram(contemporaneously with researchers in Scandinavia and North America), theirmodel for thinking about treatment for ‘‘chronic alcoholism'' was a methoddeveloped some 15 years earlier: conditional-reflex therapy, sometimes referred toas ‘‘apomorphine treatment.'' While the idea of inducing a physical aversion toalcohol in patients was not new in itself, Soviet medical researchers had groundedtheir efforts in Pavlov's theories: after initial attempts using electrical shock, theysettled in 1933 on the use of emetics like apomorphine, to condition subjects so thatthey experienced a nausea reflex upon tasting or smelling alcohol (Sluchevsky and 11 Hypnosis and suggestion were also central to the research of Vladimir Bekhterev, the eclecticpsychiatrist who developed a theory of ‘‘associative reflexes'' in many ways parallel to Pavlov's, and whois often described in the Soviet literature as the ‘‘founder of Russian psychotherapy'' (Platonov p. 11).
Cult Med Psychiatry (2010) 34:132–168 Friken Zhislin and Lukomskii ). Between the 1940s and the 1980s in theSoviet Union, conditional-reflex therapy was a recommended mode of clinicaltreatment for alcoholism, given pride of place in textbooks as a first-line therapy foruse after detoxification and mandated at LTPs and other penal institutions (Shtereva; Babayan and Gonopolsky 12 Even following the post-Stalin liberal-ization of science, conditional-reflex therapy remained prevalent in Sovietpsychiatry and narcology because it complemented the needs of planners andadministrators.13 When disulfiram was introduced in the Soviet Union, use of the therapy was modeled after that of conditional-reflex therapy: indeed, many of the earliestpublications about disulfiram in the Soviet medical literature were authored by IvanVasil'evich Strel'chuk, who also developed widely employed protocols forapomorphine treatment, some using methods of hypnotic suggestion (Strel'chuk, ; Miroshnichenko et al. , p. 139). Patients were not simply told ofthe potential negative effects of drinking alcohol while on the drug; these effectswere demonstrated to them in physician-administered ‘‘tests'' (Strel'chuk ;Babayan and Gonopolsky Moreover, disulfiram treatment was seen asdeveloping in the patients a ‘‘negative conditioned reflex to alcohol,'' and this reflexwas observed even in ‘‘patients who had not taken antabuse in nearly a year''(Strel'chuk , p. 49). In other words, the notion that patients might have theintended physiological reaction to disulfiram in the absence of the drug itself waspresent almost from the inception of its use in the Soviet Union. It is thus notsurprising that, by the late 1960s, Soviet researchers were reporting clinicalexperiments with the use of placebo therapy, literally the replacement of the drugwith a saline solution or vitamins (Ialovoi ). While this was originally intendedfor patients for whom the drug was contraindicated, the use of such placebo therapybecame increasingly widespread (Fleming et al. Subdermal implants of the French Esperal quickly became the most popular application of disulfiram: patients would have a capsule implanted behind theirshoulder blade and warned of possible adverse effects from taking alcohol for aperiod of from one to five years (Fleming et al. While other placebo therapieswere also used, such as the ‘‘tablet'' and the ‘‘torpedo'' (these were represented topatients as oral and intravenous forms of ‘‘long-acting'' disulfiram, respectively),implantation was by far the most popular (Chepurnaya and Etkind Amongpatients and relatives the therapy was referred to colloquially as an ‘‘implant''(podshivka), and patients would commonly say, ‘‘I was implanted'' (meniapodshili). Narcologists referred to all of these variants of disulfiram or placebotherapy as khimzashchita. Such treatment remained extremely common amongpatients I spoke to in 2004, and some returned regularly for repeat implantations.
If disulfiram treatment had first been conceptualized in the Soviet Union as an aversive treatment like conditional-reflex therapy, its transformation into khimzashch-ita involved several key shifts. Where conditional-reflex therapy hinged on patients' 12 The use of apomorphine treatment was not confined to the Soviet Union, although its use was lesswidespread elsewhere (Dent Lemere White , pp. 106–108).
13 By the time of my fieldwork, apomorphine therapy was no longer in use in St. Petersburg.
Cult Med Psychiatry (2010) 34:132–168 bodily memories of past experiences, khimzashchita worked on their anticipation ofpotential future consequences. Moreover, while the former depended on a behavioralresponse to stimuli administered within the walls of the clinic, the latter transposed thesource of this stimulus into patients' own bodies. Underlying these was an even morefundamental conceptual shift: whereas conditional-reflex therapy depicted the patientas a body responsive to inherently meaningless stimuli, khimzashchita assumed asubject replete with expectations, emotions and beliefs.
Most narcologists described khimzashchita as a form of psychotherapy and emphasized its parallels with a type of hypnosis known as emotional-stresspsychotherapy or ‘‘coding'' (kodirovanie). Developed during the 1970s byAlexander Romanovich Dovzhenko, a physician working in Crimea, coding wasa variation on other forms of hypnotic treatment for alcoholism (e.g., Rozhnov andBurno ). It became popular as a ‘‘rapid'' form of therapy during the 1980s and1990s, often in an extremely commercialized form where it was depicted as amagic-bullet cure (Dovzhenko et al. ; Miroshnichenko et al. p. 79). Likekhimzashchita, coding is a therapy meant to keep patients from drinking seeminglyby convincing them that their brains have been altered so as to make theconsumption of alcohol harmful or fatal. Unlike khimzashchita however, codingdoes not involve the ingestion, injection or implantation of any substance at all, andit is the therapist who ‘‘alters'' the patient's brain through his or her actions.
Narcologists and patients alike often implicitly acknowledged the similaritiesbetween khimzashchita and coding by classifying them together. Proponents of thetherapies have called them ‘‘mediating psychotherapy'' (oposredovannaia psikho-terapiia) in print, and many patients refer to both types of treatment as coding (Entin, p. 132). In addition to highlighting the fact that purportedly disulfiram-basedtreatments are viewed as entirely suggestion-based (rather than physiologicallyactive) therapies, this classification also foregrounds a number of formal similaritiesbetween the clinical techniques.
‘‘A Small Ritual'': Making Placebo Therapy Effective Not only did an education in narcology or psychiatry shape Russian physicians'acceptance (relative to their North American colleagues) of hypnosis and placebotherapy as viable treatments, but also it made them particularly attentive to the linksamong the performative elements of the clinical encounter, the patients' belief andknowledge and the effectiveness of therapies. For narcologists, the khimzashchitaprocedure begins with their description of the treatment to their patients, duringwhich they must deliver a compelling depiction of its physiological effects. I askedAnton Denisovich, the young physician who ran the ward where Vyacheslav wasbeing treated, to explain khimzashchita as he would to a patient: We inject the medication disulfiram. It comes in different forms: intravenous,capsule form or subdermal implantation. All of these forms are long-acting. Ifthe medication is taken intravenously or orally it dissolves in the stomach andends up in the blood stream and then enters the body's tissues, combines with Cult Med Psychiatry (2010) 34:132–168 proteins in the liver … and for a certain period of time this medicine remainsin the bloodstream. This medication cannot be taken with alcohol as it blocksthe enzymes which break down alcohol. If a patient on this medication drinksand alcohol enters his bloodstream the possible side-effects are dangerous tohis health or life-threatening. It can be anything from a flushing or reddeningof the face, to serious or crippling consequences, or even death…. This is toldto the patient and he signs a paper explaining that he understands theprocedure. And then the procedure takes place.
As Anton Denisovich himself acknowledged, this statement was often untrue in a referential sense, as he often used placebos in place of disulfiram. Like othernarcologists, he treated the statement as a perlocutionary speech act meant to fosterin the patient a particular belief (that a chemical agent in his body has made theconsumption of alcohol potentially deadly), an accompanying affective state (that offear, stress or concern) and a consequent behavioral change (abstinence).14 Perhapsmost importantly, a central idea implicit in such treatments is that clinicaleffectiveness depends on patients' belief in this ‘‘truth'' about their bodies, acondition which the statements are meant to bolster. Even the ‘‘paper'' whichpatients sign to acknowledge that they ‘‘understand the procedure'' often functionsperformatively, as a prop which aids the physician in delivering the intended effect,as much as a contract meant to inform patients and verify their consent.
Following these key preliminary steps, the clinical interaction at the core of khimzashchita takes place. Alexander Sergeevich, a narcologist at the AddictionHospital, explained in strikingly clear terms how crucial a clinical performance is tothis stage of khimzashchita (and related treatments): Everything hinges on one short action, either in coding or in our methods ofplacebo-therapy: in other words a small ritual [malen'kii ritual'chik]. Either atouching of hands to the head, some kind of words, the use of some substancewhich gives a sensation: maybe a local anesthetic is poured into the throat.
This ritual just signifies a point in time when the period of sobriety begins.
This exists in all versions of psychotherapy.
It is worth noting that, like others at St. Petersburg's Addiction Hospital, Alexander Sergeevich did not regard himself as an ‘‘alternative'' practitioner but,rather, as a mainstream psychiatrist–narcologist. His account further highlights thedegree to which the disciplinary assumptions of narcology attuned clinicians to viewperformance as part of their practice. Alexander Sergeevich emphasized theimportance of ritual form over content (physical contact, words or substance areinterchangeable) in producing a meaningful temporal demarcation of a new ‘‘periodof sobriety'' for patients. Following this logic, narcologists' and patients' preferencefor implantations and injections over daily self-administered tablets takes on an 14 While he was perhaps more frank in our conversations than other physicians, Anton Denisovich was inno way unusual as a physician. If anything, he was seen as an exemplary and especially promisingclinician. Described by the hospital's medical director as a young star, Anton Denisovich had beenappointed the head of his ward only 4 years after completing his MD in 2000.
Cult Med Psychiatry (2010) 34:132–168 additional significance, since such methods of application allow for yearly or half-yearly markings of ‘‘sober time.''15 Many of the patients with whom I discussed khimzashchita repeatedly spoke about the material aspects of the treatment: the size of the ampoules, the place on theirbodies where Esperal' was implanted, the mode of administration—patients ascribedparticular meanings to all of these characteristics, which in turn mediated theirassumptions about the potential efficacy of the therapy. ‘‘They have ampoules, aboutthis size and bigger ones,'' Vyacheslav explained when I asked him to describe thetreatment, indicating the size with his fingers. Torpedo injections were typically dyeda bright pink or blue to signify their chemical potency (Fleming et al. p. 360).
The mode of administration was certainly important as well: the fact that patients andtheir families generally preferred implants to injections, which, in turn, they favoredover tablets, suggests that more physically invasive methods of administration mayalso have been associated with greater efficacy or potency. At the same time that theyreplaced disulfiram with vitamin C, saline or other neutral substances, narcologistsused various methods to reinforce patients' interpretation of the treatment as beingchemically potent. A narcologist interviewed by Chepurnaya and Etkind (par. 9) explained that he sometimes carried out sham surgery on patients—makingand sewing up an incision without implanting anything—and then prescribedchemically active disulfiram tablets, telling patients they were taking an antibiotic.
Patients also recognized the objects and substances used in khimzashchita as commodities and they often linked a drug's potency and value to its geographicalpoint of production. One such account came from Sasha, a slight, gaunt man in his late40s from a working-class family, who had spent the majority of his life imprisoned foracts (mainly burglary) committed while intoxicated. Sasha was a typical candidate forimplanted disulfiram, the mode of treatment which was particularly popular for thosecategorized as noncompliant by their relatives or physicians.
Then I ended up in the hospital again. My mother had some friends who weredoctors and they said, ‘‘Let's give you an implantation of Esperal.'' I said‘‘Mom, what is this?'' and she explained it all to me, and so I agreed to it. Forfive years. They ordered this Esperal through the head doctor. I went through afull physical and then I had to bring a petition from my workplace[khodataistvo] and they implanted me [menia podshili]. I didn't drink for ayear and a half. During that time I entered the institute for ship-building, anddidn't drink. And then I had a relapse when a friend of mine died, with thesame type of implant. Somehow I started to think, ‘‘Maybe nothing willhappen to me.'' And I had a relapse. They had to revive me, but I survived.
Obtaining imported pharmaceuticals (in this case the French Esperal) during the Soviet period typically meant circumventing formal channels to draw on extensive 15 This temporal aspect of the treatment also complemented the way in which the heavy consumption ofalcohol was conceptualized by many patients in St. Petersburg. Patients I met at various institutions rarelyspoke in terms of ‘‘consuming'' or ‘‘drinking'' alcohol. Most referred to ‘‘entering'' and ‘‘exiting'' drinkingbinges (zapoii), in a way which suggested a separate time and space. While the phenomenon of drinkingbinges is prominent in the international medical literature on alcoholism, this local vernacularunderstanding of a binge—and the set of practices it described—was clearly distinct from the medical one.
Cult Med Psychiatry (2010) 34:132–168 networks of contacts, a practice known as blat (Ledeneva As was the casewith many goods and services, the scarcity of such pharmaceuticals, the effort andaccess required to obtain them and their place of origin all added to their value—and, in this case, their perceived potency.
By the 2000s, the availability of these substances had changed (typically the chief obstacle for patients was now a lack of money rather than a lack of access), butmany patients and physicians continued to ascribe greater potency to implantsimported from France or elsewhere over their domestic equivalents. One patientrecounted the choice he had heard a doctor offering an acquaintance: ‘‘[Thenarcologist] says: ‘I can give you our domestic [otechestvennaia] khimzashchita—itcosts 1,900 rubles [about $65 in 2004]. I can't guarantee that it will work, if youdrink that something will happen. Or I can put in the French one—that one costs[significantly more]. This is a 100% variant.''' In ascribing greater potency toimported disulfiram over the Russian-made variety, physicians and patientsemployed a common form of postsocialist consumer judgment which links materialvalue to an object's geographical place of production (Patico ). Moreover, theyimplicitly translated commodity value into a judgment of potential clinical value orefficacy.
Secrets and the Management of Belief Khimzashchita was a delicate topic for many narcologists. While some spoke aboutthe use of ‘‘placebo therapy'' without trepidation, in other cases bringing up thetopic of placebos led to awkward pauses or attempts to circumvent the question.
During one conversation with two narcologists who worked on the same ward, theolder of the two brought up the topic of disulfiram, explaining to me that ‘‘here it isstill used.'' This is mainly implantation? Younger narcologist: Implantation or intravenous injection— Older narcologist: No, intravenous, this is already called emotional-stresspsychotherapy. This doesn't involve the use of disulfiram.
Why? What's the difference? Younger narcologist: Well, these are already professional nuances. Butbasically, there are three methods of taking themedication—either tablets, implantation or intravenous.
Older narcologist: Here there is a difference which depends on thepsychological particularities of the patient.… The activesubstance, disulfiram is applied only in one form—implantation. [sic] But … sometimes people are either alittle afraid of this, everyone has there own particularities,and they aren't suited for this. A better fit for them isemotional-stress psychotherapy, which is accompaniedby the application of, essentially a placebo.
Cult Med Psychiatry (2010) 34:132–168 Here the younger narcologist, seemingly unsure of how to deal with the issue of placebo therapy, attempted to portray the difference between the use of aphysiologically active substance and a placebo as a meaningless technical detail:‘‘professional nuances.'' While his older colleague was ready to bring me in on theprofessional secret, he was at pains to emphasize that active disulfiram was used inimplantations.
Once they knew I was in on their secret, narcologists offered a number of explanations for how they chose to give patients neutral substances in place ofdisulfiram, suggesting a subtle moral and social calculus which underlay theirreasoning about clinical effectiveness. Anton Denisovich explained: ‘‘As youunderstand all patients cannot take these substances, in part because some of themwon't wait out the entire period, and this will just be dangerous for them. So it'sbetter to give him a placebo and give him the gift of several months of sober life,than to inject the real medication.'' While I discuss this framing of the placebo as agift at greater length below, it is worth noting that decisions to administer neutralsubstances were underpinned by judgments of particular patients and their capacityfor adherence. A strong DER could indeed be deadly to some patients, andnarcologists often sought to mitigate risks to their patients, as well as their ownpotential liability, by using placebo therapy. Although most verifiable accounts ofpatients dying from a DER seemed to be clear cases of negligence on the part ofphysicians, narcologists at the hospital depicted noncompliant patients as theprimary source of risk.16 Judgments about patients' potential for adherence, in turn, drew on a categorization of patients based on their familial resources as well as an ascribedlevel of ‘‘social decline.'' In a recent textbook, Russia's head narcologist Ivanets() recommends the use of disulfiram only for the small contingent of patientswho remain ‘‘socially conserved'' (sotsial'no sokhranen) and argues against its usefor the vast majority, which he characterizes as ‘‘the asocial type [asotsial'nyi tip] ofalcoholic'' (pp. 113–114). Narcologists I spoke to articulated a similar logic. For thephysicians, this way of thinking rendered their perceptions of respectability andsocial status clinically relevant, as indices of a patient's potential adherence.
‘‘Socially conserved'' patients included those who had not (yet) lost their jobs orcontact with their family members; they were viewed as having greater motivationfor sobriety, but also as possessing greater social and familial resources to facilitateadherence. ‘‘The real medications have so many side-effects,'' explained onenarcologist. ‘‘We give it if there is a mother or a wife who strictly makes sure thatthe patient is taking the medication. Then we give it.'' In other words, the use ofchemical disulfiram at the clinic was often seen as being dependent on acomplementary (typically gendered) arrangement for its management in a domesticspace.17 16 Most cases of patient deaths after disulfiram implantation or injection involved commercial enterpriseswhich offered the service of at-home disulfiram treatment. This procedure was sometimes carried outwithout checking the patient's current blood alcohol level, and the house-call teams often leftimmediately after completing the procedure.
17 This clinical style of reasoning also drew on and fed into a widely circulating discourse about ‘thesocial,' which has its own deeply Soviet genealogy. Both physicians and patients themselves spoke about Cult Med Psychiatry (2010) 34:132–168 If using disulfiram was especially risky for a particular category of patients, the efficacy of placebo therapy was also seen by narcologists as highly variable. Someargued that placebo therapy was more effective among certain types of patients,typically identifiable by particular psychological characteristics. For narcologists,patients' suggestibility could be conceptualized as either an individual disposition ora generational characteristic. Older patients or ‘‘Soviet people'' were oftendescribed as being more suggestible than younger people, an ascription whichdraws on a common stereotype of the sovok or Homo sovieticus as conformist andprone to manipulation by political propaganda (cf. Oushakine At times, such patients were described in terms of their tendency or capacity for ‘‘belief'' or ‘‘faith'' (vera). Indeed, narcologists partook of an understanding of‘‘belief'' which, as Byron Good (has argued, is central to the empiricistparadigm underlying the ‘‘folk epistemology'' of biomedicine (p. 5). Implicitlydichotomizing belief and knowledge, most narcologists cast themselves as rationalactors who ‘‘know,'' in contrast to patients who merely ‘‘believe.'' The disciplinaryassumptions and clinical techniques of narcologists may have fostered a particularattention to the relationship between this ‘‘belief'' and the effectiveness ofkhimzashchita and other therapies.
Even further, some physicians characterized ‘‘belief'' in particular therapies as a sort of nonrenewable resource requiring careful management. In a recent paper,Alexander Sofronov ), a well-respected professor of psychiatry at St.
Petersburg's Military Medical Academy, argues that the popularity (amongpatients) of modes of treatment such as khimzashchita hinders the advancementof methods accepted throughout the world, particularly the Twelve Step programand the therapeutic community model. Sofronov ) describes clinical technol-ogies of khimzashchita and similar methods as ‘‘explanatory medicine''(ob''iasnennaia meditsina), in which the patient's only source of knowledge orinformation is assumed to be the physician: ‘‘The way we explain it is how they'llbe treated'' (p. 4). Despite his misgivings, Sofronov regarded methods such askhimzashchita in a highly pragmatic way. During a conversation in his office,Sofronov posed a rhetorical question about the popularity of such treatments:‘‘Should we undermine this belief (vera)? Absolutely not!'' While Sofronov thoughtthat ‘‘explanatory medicine'' blocked the growth of more effective modes oftreatment, he also worried that the latter were not yet adequately developed oravailable to patients in Russia. Not only was it unethical to undermine patients' faithin khimzashchita under such conditions, but also, as Sofronov implied, belief in theefficacy of treatments needed to be carefully managed.
In other words, if the effectiveness of khimzashchita hinged partly on narcologists' skills of persuasion and performance in their face-to-face encounterswith patients, it was equally dependent—as the physicians saw it—on theirsuccessful management of its broader representation to various publics as a Footnote 17 continuedthe position of particular persons vis-a -vis ‘‘society''—as being still within it, outside of it or, more rarely,re-entering it. The implication was that patients described as ‘‘socially destroyed'' or ‘‘declassed'' notonly had lost contact with their relatives and friends, or had lost their previous standing, but were beyondthe boundaries of the social altogether.
Cult Med Psychiatry (2010) 34:132–168 pharmacological treatment, and as an effective one at that. This work of buildingand maintaining the treatment's legitimacy took place not only during narcologists'bedside chats with their patients, but also in conversations with family members, indebates on the pages of medical journals and newspapers, and in arguments oroffhand remarks made to this ethnographer.
For example, when I asked Anton Denisovich whether he ever administered chemical disulfiram, he replied, ‘‘You understand that we can't give every singleperson the placebo, because we'll discredit the method that way.'' Not only did thisanswer suggest a widespread anxiety that khimzashchita might easily lose itseffectiveness by becoming associated with placebo therapy among patients, but thestatement was itself aimed at maintaining the legitimacy of the therapy. Whether ornot chemical disulfiram was ever used, it seemed that it was important to tell me thatit was, at least sometimes used, lest I depict the entire therapy as a sham, as othershad done.
In working to legitimate khimzashchita physicians used multiple strategies, ranging from quoting statistics of efficacy (typically percentages of patientsachieving year-long sobriety) to constructing origin stories for treatment modalitieswhich linked them to Russia and depicted them as culturally appropriate. Forexample, the argument was sometimes made that it was appropriate for physiciansto employ their professional authority to frighten patients because this clinicalrelationship reflected a particularly ‘‘Russian'' form of authority. Moreover, asnarcology in 2003–2004 was a thoroughly commercialized sphere of medicine, inwhich practitioners competed fiercely for patients, claims about the efficacy of one'smethods and medications were often interspersed with disparaging comments aboutone's competitors as manipulators, cult leaders, quacks or even mentally ill. Onepsychiatrist in private practice explained to me that his use of subliminal suggestionmethods represented one of the few clinical uses of the ‘‘real'' technology. Theattempts of others he described, ironically enough, as ‘‘placebo therapy at best.'' Doubts, Rumors, and Fears: Patients' Ideas About Khimzashchita What effect did narcologists' efforts have on patients' understanding ofkhimzashchita? The answer often had to do both with a particular patient's priorexperiences in treatment and with the broader social context of his or her life. Whilepatients' descriptions of khimzashchita ranged from confused to compliant todefiant to desperate to cynical, it was most often the patients with jobs and intactfamilies—those likely to be viewed as potentially compliant—who spoke about thetreatment in a manner likely to be understood as ‘‘believing'' by their physicians.
For example, Gleb, a middle-aged working-class patient on Anton Denisovich'sward, explained that he had been given a torpedo in the past, but had not been ableto wait until it ran its course, and had begun drinking. He added that nothinghappened as a result of his drinking during the course of the torpedo. Yet the factthat he had, contrary to the assurances of his narcologist, survived this relapsewithout any consequences did not lead Gleb to doubt the potential dangerousness ofkhimzashchita: Cult Med Psychiatry (2010) 34:132–168 Before you take it you sign a paper saying that if you drink, the doctors are notresponsible for what happens to you. You get it for a year, then you have to waitit out for a year. If you do it, you want to live. It's fine if it kills you: better thatthan it paralyzing you or something. We don't know with these drugs. Thatwould be worse. So each person needs to use his brain. [Emphasis added] Gleb's description evokes the state of uncertainty experienced by many patients with regard to the risks of khimzashchita. Indeed, many stories circulated in St.
Petersburg about deaths caused by disulfiram. Some of these were offered bynarcologists as condemnations of the rapacious commercial practices of theircolleagues. Others had the quality of rumors or warnings: accounts by patients ortheir relatives told about acquaintances who had died because of khimzashchita. Iwas also told apocryphal stories which attributed the death of popular Soviet singerVladimir Vysotsky in 1980 to a particularly serious disulfiram reaction. Manypatients also spoke about the importance of having an implant removed beforebeginning to drink (Chepurnaya and Etkind Whatever the intentions ofpeople who circulated such rumors, the narratives themselves played an importantpart in reinforcing the idea of khimzashchita's potency among laypeople.
However, for every story about the chemical potency of the treatment, there was another which attested to its ineffectiveness or offered a technique for counteractingdisulfiram's effects. Dmitri, a Twelve Step counselor, showed me the scars whichimplantations of Esperal had left on his body and explained that he had never waitedthrough the term of the implant and never had one removed.
I would just start to drink. And nothing happened. Besides that, I knew thatnothing would happen: everyone was constantly talking about this. They'dsay, ‘‘Forget it, just drink a little lemon juice.'' There were all of these meansto counteract it that they'd give out right away, even while you were still in theward, getting ready for the operation. Even though I would wave these ideasaway, they would sink in somewhere.
Physicians recounted their own stories (typically told in a comic mode) about patients who tried to manually remove or destroy their implants by tearing at theirshoulders or striking their backs with sticks. All of these narratives contributed topatients' pervasive sense of uncertainty surrounding khimzashchita.
Ironically, the patients who received placebo therapy because they were categorized as noncompliant were the very ones who were least likely to givecredence to the potential efficacy of narcology's treatments. Eduard, an unemployedman in his mid-30s, whom I met at the hospital, was one such patient. During thelate Soviet period, Eduard had worked as a fartsovshchik, a black-market dealer ofgoods from capitalist countries such as blue jeans, but he had been unable tomaintain steady work for several years. When I spoke to him, his arm was bandagedfrom a burn he had received while cooking drunk. Eduard was doubtful of anytherapies, and described how he had seen another patient receive an Esperalimplantation, which her physician explained was foolproof option: ‘‘If you don'twant to live you can just drink a glass of beer and you won't be here any longer.''However, Eduard continued, after the patients' discharge, ‘‘One week later they Cult Med Psychiatry (2010) 34:132–168 bring her back—after a week-long binge already! Almost comatose. So all thesekhimzashchity are complete nonsense.'' Eduard could easily have interpreted hisacquaintance's serious condition upon her return to the hospital as an indication thatthe disulfiram had been active and potent. Instead, he emphasized that this patienthad—however narrowly—survived her binge, despite the assurances of herphysician, as evidence that the treatment was ‘‘complete nonsense.'' It is particularlyinteresting to compare this account to that of Gleb (described above), who did notdoubt the potential dangerousness of khimzashchita, despite having experienced nophysiological effects as a result of a previous torpedo. Unlike Eduard, who wasliving on the margins of homelessness, Gleb resided with his family. LikeVyacheslav, Gleb had integrated khimzashchita into his domestic life.
As the contrasting accounts of Gleb and Eduard suggest, patients' dispositions toward the efficacy of khimzashchita may be more shaped by the overall contexts oftheir lives, their motivations and hopes for sobriety and the legitimacy which theyaccord to medical institutions, than by specific experiences of efficacy or lackthereof. Indeed, if the standard account suggested that khimzashchita relied onpatients' fear, which in turn depended on their belief in its potency, mostnarcologists also emphasized that the treatment only worked for patients who were,like Gleb and Vyacheslav, adequately motivated for other reasons.
For instance, Alexander Sergeeivich explained how some patients used fear as a means of self-management. ‘‘The mechanism [underlying khimzashchita] is simplyfear,'' he explained, but added that one also needed a motivation to become sober.
‘‘If he doesn't have this, then even fear won't hold him back.'' Part of thephysician's work, as Alexander Sergeeivich saw it, was rendering this fearmeaningful to the patient, making sure that it took hold. He added, ‘‘Many of [thepatients], either openly or not, approach the doctor with the request, ‘Put this fear ofconsuming [alcohol] into me.' Because many of them understand that nothing elsewill hold them back, only this kind of fear.'' It was not just physicians who madesuch arguments. Dmitri, the Twelve Step counselor, described to me how he hadonce voluntarily returned to a psychiatric hospital for a repeat of a sulfazineinjection18—which he described as a ‘‘punishment'' rather than a ‘‘treatment.'' ‘‘Isaid, do this thing to me one more time. I ask him voluntarily; I want to rememberthis state [sostoianie], this horrible state, I want to experience it and remember it, sothat I'll always remember it.'' Such accounts suggest that the model patient forkhimzashchita and related methods is not the unknowing dupe of narcologists, butthe patient who successfully integrates these clinical technologies into a process ofself-management and discipline.
Dependencies: Power, Professional Authority, and the Clinical Encounter In their article on khimzashchita and related therapies, Chepurnaya and Etkind() argue that these modes of treatment represent an ‘‘instrumentalization of 18 Another relatively common practice in Soviet psychiatry and narcology, the injection of sulfazinecaused patients to experience severe pain and fever, and was used as a form of aversion therapy.
Cult Med Psychiatry (2010) 34:132–168 death'' to the purpose of controlling the behavior of others. As they see it,khimzashchita—and particularly disulfiram implantation or podshivka—is a partic-ularly ‘‘extreme'' disciplinary practice in that it requires patients to enter into aseemingly contractual and voluntary relationship with their physicians, in whichpatients agree to death as a potential consequence of their breaking the contract.19These elements also make the treatment representative of ‘‘those disciplinarypractices which were characteristic for late Soviet society and which have beeninherited by post-Soviet Russia'' (Chepurnaya and Etkind par. 4). Moreover,Chepurnaya and Etkind suggest that, paradoxically, khimzashchita harnessed theinformal practices central to Soviet society (e.g., rumors, networks of acquain-tances) to bring deviant and unruly individuals voluntarily under the power of theparty-state. They develop this argument by drawing on the political and socialtheories of Thomas Hobbes and Emile Durkheim. In agreeing to a disulfiramimplant, alcoholics put themselves under the power of a Hobbesian sovereign;however, the power of the implant can only be created and sustained by thecontinuous reiteration of belief by a Durkheimian collectivity (Hobbes ;Durkheim ).
While this interpretation nicely captures the thoroughly social character of khimzashchita, as well as its similarities to other authority-establishing practices, itprovides few tools for thinking through the contentiousness and contestation ofthese therapies. This is not to say that physicians' use of their professional authorityin the clinical encounter (and beyond) is not implicated in khimzashchita. Indeed,such treatments have depended on, and helped to reinforce, clinical encounterspremised on a steeply hierarchical physician–patient relationship. Not only didnarcologists frequently make direct reference to their professional status in theirconversations with patients and their families, but the entire process ofkhimzashchita depended on patients' ascription of authority to their physicians.
However, since the legitimacy of narcology as a medical specialty was deeplycontested, such ascriptions varied greatly depending on the patient and on the abilityof the physician to embody this authoritativeness. Many of the older male patients,such as Vyacheslav, expressed a strong deference to the specialist authority ofphysicians in matters of medication: ‘‘It's all figured out by the professors so that itgradually dissolves.'' Yet there were always patients like Eduard who viewednarcologists as motivated entirely by pecuniary concerns. Particularly because ofthe contentiousness of this medical specialty, it is important to look beyond thecharisma of individual physicians or the symbolic power of white coats and surgicalscalpels, to examine the institutional context in which narcologists staked theirclaims to professional authority.
As Rivkin-Fish () has argued, physicians' specialist authority took on a different shape in the Soviet Union than in liberal Western European and NorthAmerican states (pp. 23–28). While the Soviet party-state celebrated the specialistpower of medicine, it also undercut physicians' bases of corporate power orautonomy by dissolving pre-Revolutionary professional associations (Field 19 Chepurnaya and Etkind attribute this character of khimzashchita to the fact that, unlike the disciplinarypractices described by Foucault (), it emerged from an illiberal society rather than a liberal one.
Cult Med Psychiatry (2010) 34:132–168 Not only did physicians become employees of state agencies, but their potentialclaim to a class- or status-based differentiation was curtailed through the scaling ofmedical wages below those of industrial workers (Ryan , p. 22). Mark Field() has suggested that the simultaneous constraint of physicians' political andeconomic power and the promotion of their disciplinary power created a situation inwhich the clinic took on added importance as a key site for the exercise ofprofessional authority (p. 53). Within the walls of the clinic the physician'sauthority was meant to be unquestioned, with no patients' rights movements or legalmeans to challenge clinicians' ‘‘symbolic power of expertise'' (Rivkin-Fish p. 26).
This dynamic was arguably intensified in the case of specialties such as psychiatry and narcology, which were more heavily dependent than others on theparty-state for their authority. In the case of narcology, this had to do with the factthat the subspecialty was a direct product of Soviet policies and campaignsregarding public order and health. Indeed the professional designation of‘‘psychiatrist-narcologist'' was only created in 1975, when the narcological systemwas established and when the Ministry of Health funded the establishment ofnarcology departments at medical schools throughout the country (Babayan andGonopolsky , p. 47; Galkin 20 Additionally, the clinical sites ofnarcology and psychiatry were closely interwoven with institutions of the legalsystem, and psychiatrists and narcologists had the authority to commit patients orrecommend compulsory treatment (Tkachevskii ).
These close institutional links to the state created a paradoxical set of conditions for Soviet physicians, and for narcologists in particular. While their ability to call onthe state's means of coercion gave narcologists a means to manage patients, it alsoundermined physicians' ‘‘legitimacy as healers'' (Rivkin-Fish , p. 26). Severalnarcologists who had practiced during the Soviet period with patients undergoing‘‘compulsory treatment'' explained the extremely deleterious effect that suchperceptions had on their attempts to establish trusting relationships with patients,especially those with histories of detention. Thus, like other Soviet physicians,narcologists often drew on various means of social exchange to personalize theirrelationships with certain patients and to distance themselves from associations withbureaucratic authority (Rivkin-Fish 21 During the 1990s, three broad changes—all linked to broader post-Soviet political and economic transformations—had significant effects on the institutionalspace in which narcologists and their patients negotiated their clinical relationships.
20 Although the term ‘‘narcology'' was not new (courses and textbooks on the topic had existed fordecades), prior to 1975 the specialty of ‘‘psychiatrist–narcologist'' had not existed as a legally recognizedand certifiable position in the Soviet medical system (Galkin ). The number of number ofpsychiatrist–narcologists rose from some 1,200 in 1976 to nearly 9,000 in 1987 (Ivanets et al. , p. 13;Fleming ).
21 Although it often involves exchanges of material value, such exchange activity—which is stillprevalent in much of the post-Soviet health-care system—was seen as falling under a separate moraleconomy from the exchange of money for services. While the latter are often characterized as bribes(vziatki), exchanges which are mediated by networks of acquaintance (svoii) are described by theirparticipants as being motivated by a desire for medical care which is personalized and not delivered by aphysician fulfilling his or her professional obligation as a civil servant (Salmi Rivkin-Fish Cult Med Psychiatry (2010) 34:132–168 First of all, during this time narcologists lost the near-monopoly over the clinicalknowledge and treatment of addiction which they held during the Soviet period andfound themselves competing with a number of methods and movements: some‘‘imported'' (like Alcoholics Anonymous [AA] and Scientology) and others‘‘homegrown'' (like the Orthodox Church) (Critchlow Lindquist ; Zigon). While many nonbiomedical practitioners borrowed heavily from narcolog-ical therapies, hybridizing them and thereby blurring the clear distinctions betweenofficial narcology and ‘‘alternative medicine,'' others were either, like some AAproponents, only grudgingly tolerant of the state-run service or, like theScientologists, devoted to an explicitly antipsychiatric and antinarcological agenda.
Thus when narcologists spoke about the effectiveness of their treatments and theneed to maintain patients' belief in them, they conceptualized themselves asoperating in this broader discursive field, where the very legitimacy of theirspecialty was constantly being called into question.
The second broad change was the transformation of narcology from part of the state socialist political economy of medical services into an unevenly regulatedmarket. The speed and depth of this commercialization were driven partly by thefact that narcology offered physicians opportunities for profit during a period ofintense economic depression. In 2004, narcologists in the state service were paidmore than many of their colleagues in other specialties—this was meant to beofficial remuneration for the difficulty of their work—while the potential for profitin commercial narcology (or unofficial services in the state sector) was so great thatcompetition between physicians and clinics occasionally turned into violentcommercial war, with the involvement of mafiya groups (Raikhel , p. 227,n. 1). For physicians or medical researchers whose small salaries were oftendelinquent or delayed for months at a time, the promise of a specialty with even amodestly higher pay scale was clearly attractive. While most of the narcologists Ispoke to had entered medicine with a variety of motivations, almost all explainedthat they had chosen to specialize in narcology for financial reasons.
This commercialization was directly linked to treatment methods such as khimzashchita, which represented one of the main sources of additional income forphysicians working in the state-run network. Not only did the treatment becomeopenly commodified during the 1990s, but narcologists spoke about its value andprice as a clinical consideration. For example, the cost of khimzashchita was oftenlinked to the length of time for which the patient was prohibited from drinking, andsome physicians described the cost of a therapy as an important element motivatingpatients to take their sobriety more seriously (Chepurnaya and Etkind par. 32). Finally, when they injected or implanted patients with a placebo, or whenthey charged an exorbitant price for disulfiram to represent it as a new medication,narcologists were the ones who pocketed the difference in cost.
The final change to narcologists' professional authority came with the abolishment of compulsory treatment laws—part of a broader effort to introduceprotections for human rights and to import principles of patient autonomy to post-Soviet Russia. Indeed, patients at the Narcological Hospital in 2003–2004 generallyneeded only to inform their physicians in writing in order to end their treatment andbe discharged. Overall, narcologists' attitudes toward this shift were ambivalent and Cult Med Psychiatry (2010) 34:132–168 varied greatly, depending on the individual clinicians and the circumstances inwhich they found themselves at a particular time. Many emphasized that the successof treatments such as khimzashchita depended largely on patients' motivation andcomplained about the passivity of patients who wanted ‘‘quick fixes'' (complaintswhich were often infused with the image of patients as wards of the welfare state).
Other narcologists—and sometimes even the same ones—groused about the need toconvince patients to stay in treatment, and spoke of the Soviet period with nostalgia.
Perhaps more significantly, even when they spoke about the importance ofmotivation, many narcologists seemed to regard the success of khimzashchita asbeing dependent on a performance of a charismatic authority which fosteredpatients' beliefs of their healer's uniqueness, rather than their own agency.
All three of these broad changes—the arrival of new forms of addiction treatment and rehabilitation, the commercialization of narcology and the demise ofcompulsory treatment—shifted the grounds for clinical relationships, so that theytook very different forms, depending on the social conditions and financial means ofparticular patients. To examine the variation in these relationships it is worthreturning to the statement made by Anton Denisovich in describing his rationale forsubstituting neutral substances for disulfiram: ‘‘So it's better to give him a placeboand give him the gift of several months of sober life, than to inject the realmedication.'' Many analyses of the clinical relationship have examined themeanings and effects of gifts given by patients to their physicians, particularly inRussia, where such practices as common (e.g., Salmi In this case, AntonDenisovich reversed these terms in describing his care for some patients through themetaphor of gifting—and arguably evoked many of the ambiguities of power andauthority in the narcological clinical encounter. Like many narcologists, AntonDenisovich depicted himself as operating under an ethics of benevolence which, attimes, was explicitly distinguished from a bureaucratic ethical regime of informedconsent (Kelly Such a dynamic was particular evident with the most ‘‘hopeless'' cases—patients viewed as abject, ‘‘declassed'' or socially marginalized. Although such patients'relationships with physicians could be characterized as beneficent, critics ofkhimzashchita were more likely to label them paternalistic or even clientelistic. As apsychiatrist who worked promoting AA in Russia put it, ‘‘Under the conditions ofthe market, the job of the doctor is to attach the patient to himself [privezat' k sebebol'nogo], to make the patient dependent on him. And underlying this is the marketand financial situation.'' Indeed, physicians' relationships with certain patientscould be characterized as having a quality of dependence. Narcologists ofteninstructed patients that they would have to return to the same practitioner were theyto decide to end their sobriety early by having a code or implant removed. In thecase of patients for whom the only alternative to the hospital was life on the streetsand in shelters, such dependencies could become particularly strong. Narcologistsallowed some patients to reside at the hospital, occasionally discharging andreadmitting them to comply with official limits on periods of hospitalization. Manyof these patients performed menial tasks around the hospital; they spoke about theirphysicians in deeply deferential and respectful terms. Such relationships ofdependence and moral indebtedness stood in stark contrast to those which Cult Med Psychiatry (2010) 34:132–168 narcologists maintained with patients who had relatively greater social andeconomic capital. These clinical interactions were structured more like commodityrelationships, in which there was an exchange of alienable services for money, andeach party walked away with no obligations to the other.
At the hospital during the period of my fieldwork, there was a distinct tension between the extremes of clinical care as beneficent gift and clinical care ascommercial exchange. This tension reflected the themes of agency and responsi-bility, framed in opposing terms of dependence versus autonomy, which underlaymany debates about addiction treatments in Russia during the 1990s and 2000s.
More broadly, the clinical relationship between narcologist and patient can beviewed in the context of the complex Russian political and social order under Putin,in which self-responsibility, initiative and personal sovereignty continue to beaffirmed as necessary traits within the economic sphere, even as markedly illiberalrelationships of beneficence and obligation are affirmed within the political sphere(Rivkin-Fish ; Matza ). However at the hospital, the distinction betweengift- and commodity-like clinical relationships was largely mediated by patients'social and economic capital, itself linked to the—often downward—trajectories oftheir lives.
Conclusion: Radical Measures or Pragmatic Means Throughout this article I have traced the reasons for the continued prevalence ofkhimzashchita and other suggestion-based methods of treatment for alcoholism inRussia. I have argued that, in part, such methods arose from a professionalethnopsychiatry characterized by a particular neurophysiological style of reasoning,originally grounded in a ‘‘dialectical'' interpretation of Pavlov's theory of ‘‘highernervous activity,'' but since then transformed into a pragmatic materialism.
Narcologists view the effectiveness of such treatments as being dependent on anumber of factors, including not only individual patients' motivation for sobriety,but also their ‘‘belief'' or ‘‘faith'' in these very techniques. While physicians'attentiveness to the legitimacy of their therapies is shaped by a particular clinicallogic, at stake is the broader legitimacy of their specialty as well as its commercialviability. Moreover, as they draw on their professional and institutional authority tomagnify the effects of khimzashchita, narcologists often reinforce a steeplyhierarchical clinical relationship—particularly when they work with patients whohave few social or economic resources of their own.
There is, however, a caveat in that, despite its continued prevalence, many narcologists I spoke to described khimzashchita as ‘‘a thing of the past.'' The collapseof the USSR, and the subsequent reintegration of narcologists into transnationalprofessional networks, brought them into contact not only with psychosocial modelsof addiction treatment, but also with the biologizing trends sweeping globalpsychiatry. Even as various forms of talk therapy have experienced an efflorescencein post-Soviet Russia (Matza broadly biological styles of reasoning in Russianpsychiatry have been reinforced by this dovetailing of geopolitical rupture anddisciplinary shift. Thus it was not so surprising that some narcologists I spoke to Cult Med Psychiatry (2010) 34:132–168 articulated a disdain for khimzashchita and a hope for therapies which would ‘‘cure''alcoholism through biological means. When I asked Vyacheslav's doctor, AntonDenisovich, which methods of treatment or rehabilitation he found most effective, heexplained: Out of what now exists in the sphere of rehabilitation—these are all palliativemeasures, not radical ones. The future is certainly with psychopharmacologyin this situation, as I see it. If we look far ahead, either neurosurgery orgenetics, I don't know, but with some kind of radical measures. Psychotherapycan only more or less lengthen the remission.
Denisovich's future-oriented notion of ‘‘radical measures'' which might completely ‘‘cure'' addiction echoed many North American biological psychiatrists'hopes for an effective pharmacological treatment of addiction. However, the tensionbetween this hope and Denisovich's daily work at the Addiction Hospital, where hecontinued to employ khimzashchita regularly, reflected the uneasy and paradoxicaldisposition of many narcologists with regard to their clinical techniques. Whatevertheir aspirations, narcologists in Russia continue to work in a setting shaped byinstitutional, political–economic and cultural vectors conducive to the persistence ofmethods such as khimzashchita.
What broader conclusions can we then draw from the case of disulfiram therapy in Russia? For one, this narrative calls into question the argument that a somaticnotion of the self follows from a thoroughly biologically based psychiatry. In thecase of Russian addiction medicine, a style of reasoning which privileged biologicalexplanations did not produce treatments which encouraged patients to think of theirdrinking problems as imbalances to be modulated. Nor did most patients whoreceived narcology's behavior modification treatments articulate an illness-basedaddict identity, as advocated by Twelve Step programs. Vyacheslav did not speak ofhimself as ‘‘an alcoholic,'' but as someone who was managing his drinking binges.
Thus, in what may seem a paradox from the purview of North American psychiatry,in Russia a neurophysiological style of reasoning facilitated the dominance oftreatments which relied on largely psychological mechanisms, and which seemed tomake few claims on patients' selves or identities.
Was khimzashchita—by any criteria—an effective treatment? While I do not address this question through the analytic of clinical efficacy, I have suggested thatwhile some patients found it useless as a means of achieving even temporarysobriety, and others passed through cycles of increasingly brief remission, at leastfor some, like Vyacheslav, khimzashchita worked as a pragmatic aid for the care ofthe self which bolstered personal motivations for sobriety. The reason for thesedifferences had less to do with anything specific to the treatment protocol than withthe broader configuration of institutions and relationships (both inside and outsidethe clinic) within which any particular instance of the treatment took place.
It is in this sense that the case of Russian disulfiram treatment also demonstrates vividly that ‘‘chemical'' and ‘‘placebo'' effects, or the social and pharmacologicallives of medicines, cannot be disentangled as easily as some anthropologists havesuggested (Whyte et al. ). The addiction therapies discussed here highlight howthe efficacy of all ostensibly pharmacological treatments is shaped by elements, Cult Med Psychiatry (2010) 34:132–168 including chemical effects and patients' interpretations of those effects, clinicalperformances and relationships, clinicians' styles of reasoning and local researchtraditions and the institutional and political–economic settings of treatment.
Moreover, such a perspective suggests how partial and incomplete an understandingof any clinical intervention results when it is reduced to a therapeutic protocol, areduction which depends on the assumption that clinical technologies are discrete,portable and transposable between contexts, with little transformation.22 As themovement of clinical knowledge, substances and techniques become ever moreubiquitous and far-reaching, it is increasingly important for anthropologists ofmedicine and psychiatry to explore the processes and mechanisms which linkpatients' treatment experiences to the material, discursive, performative andinstitutional elements of which all interventions are composed.
My deepest thanks go to the patients and narcologists in St. Petersburg who agreed to share their stories with me. The fieldwork described in this paper was generously funded by aFulbright-Hays Doctoral Dissertation Research Abroad Fellowship, and further research was supported bythe Fellowship of Woodrow Wilson Scholars at Princeton University. Laurence Kirmayer has beenextremely supportive of this project during a Postdoctoral Fellowship funded by the CIHR StrategicTraining Program in Culture and Mental Health Services Research at the Division of Social andTranscultural Psychiatry at McGill University. Thanks for their many helpful comments go to theparticipants in the 2006 SSRC Eurasia Dissertation Development Workshop and the Comparative HumanDevelopment workshop at the University of Chicago, and to discussants and audience members at the2006 Society for Cultural Anthropology meeting and the 2007 American Anthropological Associationconference. This paper also benefited greatly from the readings and suggestions of Lauren Ban, EduardoKohn, Anne Lovell, Kelly McKinney, Alessandra Miklavcic, Kavita Misra, Tobias Rees, RogerSchoenman, Iris Bernblum and this journal's anonymous reviewers. Ian Whitmarsh and Hanna Kienzlergave particularly close readings and vital suggestions at critical stages of writing. Much of this paper'scontent was shaped by conversations with John Borneman, Joao Biehl, Carol Greenhouse, StephenKotkin, Amir Raz, and Allan Young.
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