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7 de mayo de 2011


A couple of months ago I got an email from Gregory Warner, the health reporter for NPR's Marketplace, who told me that he wanted to discuss my work.  Gregory had just returned from Moscow, where he had visited a clinic which treated alcoholism with what seemed to be some very strange techniques.  He'd found these treatments strange -- and interesting enough -- that he had taken his story to the producers of Radiolab, who decided that it would make an good segment of a longer show on the theme of contracts one makes with oneself.  As it happened, these were also the same methods that I had encountered while conducting my doctoral fieldwork in St. Petersburg in 2003 and 2004. While researching the piece Gregory had stumbled onto some of my published work about these alcoholism treatments and so he got in touch.

Narcologist Vyacheslav Davidov (Photo: Gregory Warner)

You can now listen to this episode of Radiolab online -- the segment on the Russian alcoholism treatment is embedded below.  But first I wanted to give a bit of extra context to the points I make in the piece.

The treatment that Gregory was introduced to in Moscow was called the "torpedo" -- but it is one of a category of treatments for alcoholism sometimes referred to as khimzashchita (which literally translates as "chemical protection") or kodirovanie ("coding").
  What unifies these techniques is that in each of them, a patient is persuaded by a clinician that his or her body has been somehow altered so as to make the consumption of alcohol dangerous and potentially deadly.  In the case of the torpedo this is ostensibly due to the effect of disulfiram -- often known as Antabuse, its trade name -- a compound that disrupts the body's metabolism of ethanol, so that someone who drinks with disulfiram in their system experiences a very unpleasant -- and sometimes dangerous -- set of effects: flushing, nausea, hyperventilation, chest pains.  Disulfiram has been used to treat alcoholism since the 1940s--when its effects on the metabolism of alcohol were discovered by Danish scientists--and was once used very widely in the US as an adjunct to other modes of therapy.  Indeed, it was a big enough deal in 1949 that Life magazine ran a story on its use as a treatment in Sweden.  Disulfiram is a somewhat unusual drug in that its effects on one's behavior are not necessarily based on its physiological effects, but on one's anticipation of those effects: it is because you know that drinking while on the drug will have this terrible effect that you don't drink.

That is precisely the aspect of the treatment that Russian treatments for alcoholism capitalize upon.  For example, patients are often implanted with what are described as subdermal depots meant to slowly release disulfiram into their bloodstream.  They are told that these will remain chemically active for months or years.  However, it has been demonstrated that commercially available implants of this type have no chemical effect after a brief period or a week or so.  Other patients are presented with injections of "long-acting" disulfiram.  In many of these cases, patients are actually being implanted or injected with chemically-neutral substances.  Indeed, the physicians I worked with in St. Petersburg regularly referred to these methods as "placebo therapy."  In other words, disulfiram plays more of a rhetorical or performative role in these interventions than a chemical one.

And in fact, there is a related kind of treatment which differs only in that it employs no pharmaceuticals at all.  The method called kodirovanie or "coding" -- developed in the 1970s by a Crimea-based physician named Alexander Romanovich Dovzhenko -- involves the therapist simply using his powers of persuasion to convince the patient that his brain has been altered so that drinking a shot of vodka may now kill him instantly.

While these various methods have recently been hybridized with New Age, occult and religious imagery, they originated in the mainstream of Soviet psychiatry, in which Pavlovian theory legitimated hypnotic suggestion by framing it in the physiological terms of “reflex action.”  I discuss this history at greater length in a recent article published in Culture, Medicine and Psychiatry.

Perhaps most significantly, alcoholism and its treatments have become a locus for debating the fraught transformation of post-Soviet Russia, as suggestion-based clinical technologies are forced to compete
with imported methods such as Twelve Step therapy. Both lay and professional discussions have focused on the question of whether these forms of treatment are appropriate in political and ethical terms. For example, Russian advocates of Alcoholics Anonymous often seek to portray suggestion-based methods as a typical “Soviet” form of authority, which “manipulates” the patient, whereas they argue that the Twelve Steps enable the patient to realize him or herself and are thus more properly “democratic” or “liberal.” According to these arguments, patients undergoing hypnotic suggestion exchange their addiction to the bottle for a dependence on a charismatic healer.

However, speaking to physicians and patients, and observing their encounters, revealed a more complicated set of realities. While many clinicians indeed have an interest in portraying their suggestion-based methods as powerful and authoritative technologies, patients undergoing such treatments do not experience themselves as controlled by some external agency—or as something akin to political persuasion. Rather many patients see treatments such as hypnosis as actually affording them relatively more autonomy—both in their everyday lives and in their self-conceptions—than Twelve Step methods, which require of adherents a full self-transformation, somewhat like a religious conversion. Rather than transforming patients’ subjectivities, these methods work by harnessing their pre-existing ideas, beliefs and affects—with an end result that is experienced as a change in behavior or practice without a change in self.

You can listen to the Radiolab segment below.  For a more detailed discussion, please see my "Post-Soviet Placebos: Epistemology and Authority in Russian Treatments for Alcoholism," Culture, Medicine and Psychiatry (2010) 34: 132-168.  A shorter version of the Radiolab story also aired on Marketplace and can be accessed here.

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