Post-Soviet Placebos: Epistemology and Authority in Russian Treatments for Alcoholism

Abstract

The dominant modalities of treatment for alcoholism in Russia are suggestion-based methods developed by narcology-the subspecialty of Russian psychiatry which deals with addiction. A particularly popular method is the use of disulfiram-an alcohol antagonist-for which narcologists commonly substitute neutral substances. Drawing on 14 months of fieldwork at narcological clinics in St. Petersburg, this article examines the epistemological and institutional conditions which facilitate this practice of "placebo therapy." I argue that narcologists' embrace of such treatments has been shaped by a clinical style of reasoning specific to a Soviet and post-Soviet psychiatry, itself the product of contested Soviet politics over the knowledge of the mind and brain. This style of reasoning has facilitated narcologists' understanding of disulfiram as a behavioral, rather than a pharmacological, treatment and has disposed them to amplify patients' responses through attention to the performative aspects of the clinical encounter and through management of the treatment's broader reputation as an effective therapy. Moreover, such therapies have generally depended upon, and helped to reinforce, clinical encounters premised on a steeply hierarchical physician-patient relationship.

Postsocialism, the psy-ences and mental health

“…The Leningrad psychiatrist V. N. Miasishchev developed an explicitly nonpsychoanalytic "theory of relationships" (otnoshenie), which he applied clinically in the form of "pathogenetic psychotherapy" (Lauterbach, 1984;Miller, 1998). A wide range of techniques relying on mechanisms of suggestion was developed by Soviet psychiatrists under the domain of "psychotherapy," becoming a chief form of intervention in treatment for alcoholism, for example (Raikhel, 2010(Raikhel, , 2016. Looking beyond the USSR, there was even greater heterogeneity, with psychoanalysis thriving in post WWII Yugoslavia (Savelli, 2013) and being practiced underground in East Germany (Leuenberger, 2001).…”

The Soviet legacy in diagnosis and treatment: Implications for population health

“…22,24,26,27 Narcology developed as a subspecialty of psychiatry in the Soviet Union in the 1970s, based in a hybrid of medical and penal institutions administered by the Ministry of Internal Affairs, in which patients could be subjected to compulsory treatment. 28 While Russia discontinued involuntary treatment for alcoholism, drug treatment services retain close ties with law enforcement agencies. 26,29 In some countries, such as Uzbekistan, narcological treatment is compulsory for intravenous drug users apprehended by the police.…”

“…Maintenance is based on khemozashchita ('chemical protection'), the application of disulfiram (an antagonist of alcohol metabolism) or neutral substances, which rely heavily on suggestions, believed by many patients, that the patient will suffer harm or death should they recommence drinking. 28 Narcology officials in Russia have strongly opposed substitution treatment for opiate dependence, despite the inclusion of methadone and buprenorphine in the WHO's list of essential medicines and extensive evidence of how substitution treatment could contribute to addressing the largely injection-driven HIV epidemic. 22 Other countries of the former Soviet Union tend to follow the Russian model.…”

“…46 The competition among providers offering narcological treatments in Russia leaves little room for a rational debate on what works best. 28 Differential payments for medical specialities, as well as opportunities to extract out-of-pocket payments from patients reveal further incentives as narcologists in Russia earn more than many other specialists. 28 Law enforcement agencies also benefit from the predominant punitive approach towards injecting drug use.…”

“…41 At least two factors are at work: the link between occupancy and funding, and a social support function fulfilled by hospitals for people who have lost their homes and employment. 28,47 Social attitudes Negative social attitudes towards people suffering from tuberculosis and drug addiction also shape diagnosis and treatment as these attitudes are often shared by state authorities and health-care providers. 21 The labelling of these patients assumes an element of coercion and social control that fosters stigmatization by wider society.…”