Eugene Raikhel's book Governing Habits is a compelling and nuanced account of historical transformations in the treatment of alcoholism in Soviet and post-Soviet Russia. Narcology, with an emphasis on hypnotic suggestion, is often denigrated as backward and authoritarian, reflecting broader discourses on Russia and its relationship to the west. Raikhel considers narcology as an aggregation of infrastructures, styles of reasoning, and therapies. As an anthropologist, he is concerned with exploring the transformation of therapeutic practices in post-Soviet narcology, using the concept of “therapeutic legitimacy,” grounded in classic and more recent literature on the production of authority and knowledge.
The ethnography is based on historical research, interviews with physicians and patients, and fieldwork at a St. Petersburg municipal narcological hospital and private rehabilitation center, among other sites. Raikhel addresses some of the methodological challenges, particularly with interviewing patients, in the introduction. Chapter 1 sets the scene with an analysis of the Russian demographic crisis after the fall of the Soviet Union, focusing on the knowledge production linking the demographic crisis to alcohol and to other post-Soviet crises. The next two chapters explore Soviet narcology, its relationship to particular forms of expertise, and its transformation in a post-Soviet context of commodification and bureaucratic patronage. Seeming nostalgia about Soviet narcology is interpreted as memories of idealized plans and intentions—the aggregation of narcology held together by a system—before narcology lost its monopoly on knowledge production around addiction and its treatment. In Chapter 4, the influence of Pavlovian reflex theory on Soviet psychiatry is related to a more physiological understanding of alcoholism and the rise of hypnotic suggestion in addiction treatment. Chapter 5 examines the practice of an Alcoholics Anonymous 12-step program in post-Soviet Russia at a private rehabilitation center, introducing the concept of “illness sodality,” or sociality around an illness identity.
Raikhel's central and most compelling claim is that the bureaucratic authority of narcology began to erode with political and economic changes during the 1990s. In the area of alcohol treatment, these changes included the end of involuntary treatment, decreased funding, and new competition. Under these conditions, the performance of charismatic authority in the clinical encounter became even more important. Therapeutic legitimacy hinges on associations with specific institutional and broader historical, political, and economic contexts. Individual patient life histories are also at play. Legitimacy is not solely or even primarily about training and technology, rather it is performed, drawing on a diverse array of informal social discourses that extend far beyond the clinical encounter. Thus, practitioners of suggestion-based therapies draw on tropes about Russian forms of authority or on symbols of Russian Orthodoxy. An AA network bolsters legitimacy through its association with the St. Petersburg visual art and rock scene. Closely attending to therapeutic legitimacy raises new questions on classic themes in medical anthropology: authority, placebo, belief, and efficacy among these.
Another claim intersects with anthropological work on the transformation of selves in post-Soviet Russia. The literature on post-Soviet subjectivities has focused on the rise of neoliberalism and self-governance. Here Raikhel intervenes to show how suggestion-based treatment differs from Foucauldian “technologies of the self,” instead functioning as “prostheses for the will.” The self is not transformed—behavior is. Twelve-step therapies such as AA in the post-Soviet context may have more of an affinity with neoliberalism, but Raikhel considers AA as a form of sociality around the illness identity, an illness sodality. Raikhel tasks anthropologists with linking subjectivities to institutions and relationships rather than specific therapies or neoliberalism. Illness sodality is meant to offer a different lens for anthropological studies of subjectivity. His insight that selves are transformed through their integration in new forms of sociality is powerful, but I would have liked it more fully grounded in ethnographic evidence of patient experiences.
Raikhel's book is an important contribution to the medical anthropology of therapeutic institutions and practices, offering new insights on the cultural specificity of biomedical and lay therapies of addiction. In Raikhel's careful account, authority, knowledge, and subjectivity are mutually transformed in the post-Soviet context. The book should be of broad use to those interested in the areas of post-Soviet healthcare, global health, and substance abuse treatment. It is also a vital contribution to the anthropology of medicine, psychiatry, addiction, institutions, and expertise.
