Eugene Raikhel. "Institutional Encounters: Identification and Anonymity in Russian Addiction Treatment (and Ethnography)." In Being There: The Fieldwork Encounter and the Making of Truth, John Borneman and Abdellah Hammoudi eds. University of California Press, 2009. more

Being There THE FIELDWORK ENCOUNTER AND THE MAKING OF TRUTH Edited by John Borneman Abdellah Hammoudi UNIVERSITY OF CALIFORNIA PRESS Berkeley Los Angeles London 200 SENDERS references Gaaz, Berthold. 1989. "Fremdenlandische Namensform und deutsches Person- alstatut: Zur Namensfiihrung der Aussiedler." Das Standesamt 6(7): 165. Herzfeld, Michael. 1992. The Social Production of Indifference: Exploring the Sym- bolic Roots of Western Bureaucracy. New York: Berg. Schwab, Sigfried. 1992. "Aussiedler—nach deutschland heimgekehrt?" Informa- tionsdienst zum Lastenausgleich 1:5. Senders, Stefan. 2002. "Jus Sanguinis or Jus Mimesis? Rethinking 'Ethnic Ger- man' Repatriation." In Coming Home to Germany? The Integration of Ethnic Germans from Central and Eastern Europe in the Federal Republic since 1945, ed. David Rock and Stefan Wolff. New York: Berghahn Books. Taylor, Charles. 1985. Philosophical Papers. Vol. 2, Philosophy and the Human Sci- ences. Cambridge: Cambridge University Press. Zizek, Slavoj. 1989. The Sublime Object of Ideology. London: Verso. eight Institutional Encounters identification and anonymity in russian addiction treatment (and ethnography) Eugene Raikhel back from the field Several months after my return from the field, I was reading online newspaper articles in the basement of NYU's Bobst Library when I came across an extraordinary story. Sergei Tikhomirov, the director of St. Petersburg's Municipal Addiction Hospital, where I had conducted much of my fieldwork, had been arrested and charged with having ordered the murder of a fellow administrator—the deputy director in charge of finances. This woman had been killed by a small bomb planted in the doorway to her apartment. The director had reported that a simi- lar remote-controlled device was placed—but did not detonate—near his apartment; it was later deemed a ruse, planted to deflect suspicions from him. Police reports suggested that while the specific motives for the 201 202 RAIKHEL murder were unclear, illicit money flows in the hospital were somehow involved.1 My initial shock at reading the article stemmed both from the fact that the violence had taken place between physicians (contract killings are still common in many spheres of business in Russia, but much less so in medicine) and from my own proximity to that violence. Though my acquaintance with the victim was limited to seeing her around the hospi- tal, I had met with Tikhomirov the previous spring when he signed off on my project—and the murder had taken place only days after I left the city. To put it mildly, the hospital had not turned out to be the kind of fieldsite I had first expected. While preparing to depart for St. Petersburg, I had been told by my graduate advisors to conduct my fieldwork with care. I had chosen to focus my research on transformations in Russian addiction medicine, known locally as "narcology," a topic which would require that I spend significant amounts of time in institutional settings—clinics, hospitals, rehabilitation centers, and the like. The danger, it was suggested to me, was that such fieldwork might prove "too easy." The idea was not sim- ply that a certain level of arduousness is necessary for fieldwork to be experienced as a "rite of passage." The concern was that the very things that made conducting research in such a setting potentially attractive— the spatial, temporal, and social structure and stability that institutions supposedly lend to one's otherwise open-ended days—would be too familiar to me, too much like the rhythms of my life at home. I would be lulled into an ethnographic complacency, unreflectingly accept the underlying assumptions of my interlocutors, and thereby lose the pro- ductive level of cognitive distance (and dissonance) needed to maintain the visibility of difference.2 Learning of the murder tragically confirmed my sense that the Munic- ipal Addiction Hospital was far from an institutional space of predictable bureaucratic regularity. As I reconsidered what it had meant to conduct fieldwork in a clinical setting where such a deadly commercial battle could take place, I returned to the broader methodological, epistemolog- ical, and ethical questions posed by clinical ethnography. In addition to the hospital, I had worked extensively in another St. Petersburg institu- INSTITUTIONAL ENCOUNTERS 2O3 tion—the House of Recovery, a 12-step-program-based rehabilitation center for alcoholics. Had my fieldwork in these two clinical spaces dif- fered fundamentally from research I had conducted outside of institu- tions? Moreover, what had I learned through this work and how had I learned it? Is what John Borneman and Abdellah Hammoudi call (in the introduction to this volume) "encounter-based fieldwork" possible in institutional or clinical settings? And finally, what experiences of mine were unique to contemporary Russia and what widespread in clinical and institutional settings (increasingly common as ethnographic field- sites) throughout the world? In this essay, I attempt to address these questions by comparing typi- cal experiences and practices of identification and anonymity in the state-run Addiction Hospital and the House of Recovery. "Identifica- tion" can refer both to the determination or recognition of "what a thing or a person is" ("identification of" or "self-identification as") and to "the becoming or making oneself one with another, in feeling, interest, or action."3 Here, I play on both meanings and their relationship with one another. I begin with the Addiction Hospital, describing the institution and my work there, and then shift to the House of Recovery. In each case, I examine how my possibilities for self-identification were opened up or foreclosed by ascriptions of identity made by my interlocutors, and how such opening up or foreclosure in turn shaped our mutual potential for identification with one another. Finally, I discuss anonymity, different types of which were central both to the House's 12-step program and to a service provided at the Addiction Hospital, known as "anonymous treatment." The essay concludes with a brief consideration of identifica- tion and anonymity within ethnographic practices. institutions: the hospital The main building of St. Petersburg's Municipal Addiction Hospital is situated on a tree-lined street of nineteenth-century buildings on Vasilievsky Island. The area was one of the first parts of the city to be laid out; the succession of parallel numbered streets, called "lines," suggests 204 RAIKHEL the Enlightenment ideals of order that Peter I and his city planners sought to impose as they constructed St. Petersburg in the eighteenth century (Lincoln 2001: 24). With the recent upsurge in the real estate market, this district in the historical center of the city has regained its status as a desir- able place to live. While some of the old housing stock still contains Soviet-era communal apartments, other buildings have been converted (back) into elite homes for the wealthy and for new professionals. St. Petersburg University lies several streets to the east of the hospital; on its other side, an avenue has been recently converted into a pedestrian walk- way lined with boutiques, cafes, beer halls, and the occasional sushi bar. In the midst of so much recent change, the cracked and dirty walls of the Addiction Hospital initially struck me as signs of deterioration or sta- sis. Like many of the city's prerevolutionary structures, the building bears visible marks of its transformation from private residence for the elite to municipal hospital. Just inside, past the landing, a large metal gate stretches across what was presumably once the main vestibule; an attendant sits in an adjoining booth, controlling traffic into and out of the clinical section of the hospital. Most of the wards are accessible only by way of the building's muddy, pitted, and overgrown courtyard where, during the summer months, patients and nurses stand by entrances to staircases, smoking and chatting. In the nineteenth and early twentieth centuries, these "black entrances" and stairwells opening onto court- yards were meant for use by servants: they are narrow and spare—con- crete stairs with unornamented metal railings. Above the doorway to one ward hangs a faded sign—designed to light up—with the words "Quiet: Hypnosis in Progress." From the mid-1970s until the late '80s the Addiction Hospital served as the hub of a municipal and regional treatment network for alcoholism and addiction in (what was then) Leningrad. The network, which had taken shape in the wake of several Soviet campaigns against "drunken- ness and alcoholism," included not only institutions (like the hospital) under the aegis of the Ministry of Health but also explicitly penal ones run by the Ministry of Internal Affairs (Beliaev and Lezhepetsova 1977; Babayan and Gonopolsky 1985; Segal 1990). These different institutions were instantiations of varying disciplinary and professional ideologies INSTITUTIONAL ENCOUNTERS 205 about the nature, etiology, and appropriate treatments of alcoholism. On one end of the spectrum were the narcological dispensaries for outpatient treatment established in each of Leningrad's administrative districts (raiony); on the other were labor colony-like institutions intended for those "chronic alcoholics who resist treatment for drunkenness, and addi- tionally disrupt labor discipline, social order [obshchestvennyi poriadok], or the rules of socialist communal life [obshchezhitiia]" (Tkachevskii 1974: 38).4 The dispensaries can be seen as representing an ideal of outpatient care espoused by early Soviet social hygienists, and the labor colonies the punitive ideal of the police and judicial systems; the Addiction Hospital was situated somewhere between these two extremes, receiving patients for inpatient treatment from the dispensaries, and occasionally sending them off to the colonies. With its "compulsory treatment" (prinuditel'noe lechenie), prolonged inpatient stays, and heavy use of medication, the hos- pital represented the predispositions and priorities of psychiatry—the parent discipline of Soviet addiction medicine.5 Though this system of addiction treatment had been deeply trans- formed by the time I first visited in 2003, the Addiction Hospital still retained many of its institutional characteristics from the Soviet period. During a preliminary research trip, I made contact with several physi- cians at the hospital: a geologist friend of the family put me in touch with Aleksei Vladimirovich,6 a medical researcher who had served as a physi- cian on several geological field trips to Crimea. Though trained as a nar- cologist, since the mid-1990s Aleksei Vladimirovich had been working as a researcher in a neurological institute and moonlighting as a lecturer on neurophysiology. However, he knew several narcologists working at the hospital, and took me along to visit a ward run by his former classmate Irina Valentinovna, a warm and personable woman in her early 40s. While the trouble experienced by Aleksei Vladimirovich in understand- ing why my research project required me to speak to physicians and patients ("Can't you just get information about narcology from books and articles?") suggested a set of epistemological assumptions very differ- ent from my own, Irina Valentinovna was more open to the idea of field- work. "In reality, things don't work the way you'd think they do if you only read texts," she agreed, setting out a tray of cookies and chocolates. 206 RAIKHEL Shortly after the fall of the Soviet Union (and close on the heels of the final Soviet anti-alcohol campaign), Irina Valentinovna explained, the Russian Federation had moved to dismantle the explicitly punitive ele- ments of the narcological system. The last of the labor colonies for alco- holics were shut down in 1994 (although they had essentially ceased to function during the late 1980s), she continued, the same year that new legislation did away with involuntary hospitalization for noncriminal alcoholics (see White 1996; Entin et al. 1997; Gilinskii and Zobnev 1998). Throughout the 1990s and 2000s, physicians at the hospital had strug- gled to manage the increasing numbers of alcoholic patients (many were now homeless, which had been rare during the Soviet period) as well as a precipitous rise of the use of injected heroin (along with a concomitant spread of HIV infection) (Kozlov et al. 2006). These efforts were frus- trated by drastic budgetary cutbacks stemming from the dismantling of the Soviet-administered economy generally and the restructuring of the health care sector in particular (Twigg 1998; Balabanova, Falkingham, and McKee 2003). While basic treatment remained free of charge, the hospital had begun to offer various for-fee services (these included improved accommodations and food). Nevertheless, Irina Valentinovna continued, with its 600 beds, the hospital was practically the only state- sponsored facility in the city offering inpatient treatment for alcoholism and drug addiction. When I returned to St. Petersburg that autumn I again contacted Alek- sei Vladimirovich. This time he put me in touch with Grigorii Mikhailo- vich, a former medical school professor who was now a mid-level administrator at the hospital. Grigorii Mikhailovich allowed me to begin speaking to physicians at the hospital, but explained that in order to inter- view patients my project would need to be approved by the hospital's director, Sergei Tikhomirov. With evident unease at the prospect of an American researcher working in the hospital, he seemed anxious to pass off responsibility for me to his superior. The process of obtaining permission to speak with patients dragged on for months. It seemed that every time I called him, Grigorii Mikhailo- vich delayed my next visit to the hospital—once a conference had come up unexpectedly, the following week everyone was busy filing their INSTITUTIONAL ENCOUNTERS 207 annual reports—yet each time he asked me to call back in several days, assuring me that a meeting with Tikhomirov was imminent. For two weeks his cell phone was dead: as he later explained, the service (funded by the hospital) had been turned off for nonpayment. I wondered whether any of this was deliberate stalling on Grigorii Mikhailovich's part. Had I failed to set our relationship in the right direction by not bringing him a gift, or was he reluctant to bring my project to the direc- tor's attention for his own reasons? Upon returning to St. Petersburg from a brief trip home to New York, I received word from Tikhomirov's office that my proposal had been for- warded to the city's Department of Public Health and that I was to write up a "research contract" (dogovor 0 sotrudnichestve) stipulating my own responsibilities, as well as those of the hospital, during the course of research. Having dutifully drafted the contract and shepherded it through the offices of several municipal administrators, I returned to the Addiction Hospital to receive Tikhomirov's signature. He was a small bearded man with a squint who seemed to spend most of his time desk- bound. After signing the document, he pointed to a clause stating that I would "present myself to patients as a graduate student in social anthro- pology." "Let me give you a piece of advice," he said. "When you speak to the patients, it's better to tell them you're a psychologist. They're used to speaking to people like that." identifications: the therapist When I had first begun fieldwork on my dissertation project, my expecta- tions about how people would identify me—as well as the methodologi- cal issues that this identification would entail—were based both on my previous experiences as an adult in St. Petersburg (a brief fieldwork trip as an undergraduate and several month-long stints of language study) and on my readings in the ethnographic literature. As I had been born in the city, then called Leningrad, and emigrated to the United States with my parents at age 4,1 was perceived by people who knew about my background as an emigre—a well-established and long-standing social 2o8 RAIKHEL category in Russia. Like all ambiguous and hybrid categorizations, this one could be interpreted in different ways by interlocutors and presented in different ways by myself, at some times emphasizing affinity between us (I was "returning home") and at other times accenting distance (I was "an American"). Language inflected my personal story as another ambiguous marker for identification. Despite my often shaky grammar, my Russian has little enough accent for me to pass unnoticed as a "for- eigner" in many everyday conversations. This ability could, however, lead to moments of abrupt discord in conversations, particularly when my interlocutor's assumption of speaking to a fluent "native" suddenly ran aground on my lack of local knowledge.7 Yet this project was different from my previous visits; I had never worked in a clinical setting in Russia, and I knew that my fieldsites, my chosen topic of alcoholism, and my interest in speaking with both physi- cians and patients would present a new set of challenges. Given my lack of medical training or experience with research in this environment, I expected to be unambiguously viewed as an outsider by physicians. However, I also wanted some entrance into the lifeworlds of patients: at the very least, I hoped to learn of their clinical experiences. I had been encouraged in graduate school to try to "follow patients home" into their domestic lives, and at the time I still thought that such an effort might succeed. Moreover, I knew that my first introductions to both patients and physicians (and the ways I would be identified by them) could either facilitate or foreclose possibilities for ethnographically rich encounters. The problem of how to identify oneself or of what "role" to assume has been particularly acute for ethnographers working in clinical settings, in part because these institutions seem to allow for so few possible ways of being. For instance, Sjaak van der Geest and Kaja Finkler have argued that fieldworkers spending extensive lengths of time on hospital wards have essentially three options in adopting a role: medical practitioner (doctor or nurse), visitor, or patient (2004:1998). The first and last of these, while seemingly offering institutionally validated positions from which to participate and observe, are difficult to assume completely. To be a practitioner, one needs specialized medical framing (increasingly com- mon among medical anthropologists, but hardly an appropriate prerequi- INSTITUTIONAL ENCOUNTERS 209 site for fieldwork); to be a patient, one must be ill or feign illness.8 Many ethnographers assume that their disciplinary practices and their institu- tional association—typically a project must be formally approved by a clinic's administrators—will mark them in the eyes of patients as associ- ated with the staff. Some fieldworkers have inhabited this association ambivalently, negotiating the methodological and ethical difficulties it poses (Rhodes 1991: 3), while others have found that the connection with practitioners fits their purposes and have sought to accentuate it (by wearing white coats and so on). On the other hand, some researchers interested in the experiences of patients—especially in settings such as psychiatric hospitals or clinics, where patients' agency is particularly cir- cumscribed compared with that of the staff—have made efforts to temper their identification with practitioners by such means as "avoiding socia- ble contact with the staff" (Goffman 1962: iv), assuming patients' clothing and physical comportment, and taking medication (Estroff 1981: 20-34). A handful of researchers have gone so far as to feign illness or its symp- toms, most often in studies of mental illness (Goldman, Bohr, and Stein- berg 1970; Rosenhan 1973; but also see van der Geest and Sarkodie 1998). Many of these studies were carried out by psychologists, whose discipline has developed a set of assumptions and practices regarding the deception of subjects that are very different from those of anthropology (Lederman 2006:484). In some cases, the strategy of posing as ill has been adopted less as a means of establishing trust among other patients than as a way of test- ing the claims of labeling theory. For instance, in a well-known study car- ried out by the psychologist David Rosenhan during the early 1970s, researchers faking symptoms of psychosis not only were admitted as patients to psychiatric hospitals throughout the United States, but once on the ward they were able to openly take fieldnotes without arousing the suspicions of staff members, who interpreted this action as pathological "writing behavior" (Rosenhan 1973: 253)^ Rosenhan's argument was that identifications of behavioral pathology are produced by physicians and patients in particular social contexts, rather than inhering fully in the bod- ies, minds, or actions of patients, and his method was central to making this argument. As I describe later in this essay, not only are the possibilities for such characterizations of oneself—as mentally ill or addicted—heavily 210 RAIKHEL contingent on local (and institutionally specific) ideas about the nature of an illness (its etiology, symptoms, visibility and so on), but the ethnogra- pher can also unintentionally become the object of such identifications. The risks of perceived connection to clinic staff have been especially important for ethnographers working in post-socialist settings, as in any place where medical professionals are closely associated with the authority of the state (Rivkin-Fish 2005; Skultans 2005). Soviet physicians were public servants; in addition, the institutional bases for their profes- sional autonomy (professional associations) had been undermined as early as the 1920s by the Communist Party (Field 1991). It has often been noted that the Physician's Oath of the Soviet Union affirmed a doctor's responsibility not only to his or her patients but also to "the principles of communist morality" and "the Soviet state" (Bloch and Chodoff 1991: 519). As Michele Rivkin-Fish has argued, this potential for being identi- fied with the state threatened physicians' "legitimacy as healers" (2005: 26), leading many to employ various means of social exchange to person- alize their relationships with certain patients and to distance themselves from associations with bureaucratic authority. Such associations vere arguably even stronger in the case of medical specialties such as narcol- ogy and psychiatry, whose clinical authority during the Soviet period had been heavily bolstered by legal provisions for compulsory treatment (narcologists sometimes called on the police to bring noncompliant patients in for visits), as well as their close relationships to the penal- juridical systems (Connor 1972; Tkachevskii 1974). Given that the most effective ways of dispelling the distrust engendered among patients by such perceived links to the state are informal practices of sociality and exchange, ethnographers working in post-socialist clinical settings have often been wary of the formality imposed by the consent forms that their home institutions require (Skultans 2005: 496-98).10 Thus, when the hospital director suggested that I identify myself to patients as a "psychologist," I grew quite concerned. For the director, such an identification was just a pragmatic methodological shortcut; he explained that introducing myself this way would expedite my interviews by giving the patients a frame of reference with which they were familiar. To be fair, some of the assumptions implicit in his proposal struck me as reasonable. For instance, it was clear that introducing myself as an anthro- INSTITUTIONAL ENCOUNTERS 211 pologist might not strike the right note, given some of the ideas circulating locally about anthropology. (One of the hospital administrators told me that upon learning of my disciplinary background he had wondered whether I planned to measure the circumference of patients' heads.) How- ever, "psychologist" hardly seemed an improvement. While I certainly hoped that patients would somehow benefit from my listening to their sto- ries, I was worried that they might misconstrue our conversations as for- mal therapy and thus assume I was a staff member. At the time, I thought there were several reasons for such a concern about misrecognition, including the range of conversations construed by local addiction doctors as "psychotherapy" and the fact that people who carried out group ther- apy or social work were sometimes categorized as "sociologists." As I began to visit the hospital regularly, it became clear that though my concerns about patients' misrecognition of our encounters were mis- placed, the best I could do to avoid being associated with clinical author- ity was to mitigate physicians' representations of me. In most cases Grigorii Mikhailovich acted as an intermediary, putting me in touch with the physicians in charge of particular wards. Most were uneasy with the idea of my spending time informally on the ward; instead, they allowed me to speak to patients individually in consultation rooms. Some went even further and insisted on selecting patients for me to speak with. One had the habit of approaching patients in the ward's hallway and asking loudly: "Sasha! Do you want to help advance international science? Just answer a few questions from our American colleague!"11 Of course, even within these relatively constrained circumstances, there was room for much difference in the framing of our interactions. Some patients were withdrawn, answered questions tersely, and resisted my attempts to open up a broader conversation about their lives. It is important to remember that we were often discussing subjects—their diagnosis as alcohol dependent or the circumstances leading to their stay at the hospital—that were, for many, difficult to speak about. My inter- locutors were primarily men, and while male drunkenness is (still) often conceived in heroic terms in contemporary Russia, a diagnosis of alco- holism continues to carry a heavy stigma. Not surprisingly, then, it was often (though not always) most difficult to have extensive and engaging conversations with the rare middle-class 212 RAIKHEL patients whose lives remained relatively undisrupted by their drinking or drug use. For instance, my fieldnotes include a rather short and abruptly ended interview with Ivan, a businessman who explained that he had been pushed into alcohol dependence because all of his business meetings (many of them, he told me, with mafiya figures) had to be con- ducted over vodka. On the other hand, many of the hospital's patients had spent significant portions of their lives in prison and assumed toward me a posture that was at once formally deferential and firmly unforthcoming. Other patients—particularly those who had been taught to narrate their life stories as "drunk-a-logs" in the local 12-step rehabil- itation program described below—were eager to relate the details of their lives. A few explicitly presented their stories to me as object lessons in moral failure or the dangers of the bottle. I had little certainty that many of these men appreciated the chance to tell their stories, and I had no doubt that they did not construe our conversations as psychotherapy. Rather, it was the physicians who were much more likely to allude to our encounters as beneficial. For instance, after several hours of conver- sation about the burdens of paperwork and stifling bureaucracy, the lack of sufficient material resources, the frustration caused by recalcitrant patients, and her general sense of futility caused by her inability to sig- nificantly affect the course of most addictions, a physician in the acute ward of the hospital exclaimed, "It's nice to be able to speak to someone about this. No one listens to our complaints." At other moments I was treated less as a listening ear and more as a colleague, a fellow "expert" (albeit in a very different discipline). Such identifications were, of course, never particularly stable—the narcologists remained keenly aware that I would represent them and their specialty—but they were sufficient to mroll me into a kind of complicity with the physicians' professional jecrets. complicities: placebo therapy \nton Denisovich was a third-generation physician and a second- generation psychiatrist whom I met early in my work at the Addiction INSTITUTIONAL ENCOUNTERS 213 Hospital. Though overworked (lacking a secretary or a computer, he spent much of his time filling out charts and forms) and underpaid (earn- ing less than he could in private practice, though more than physicians in most other specialties), he was also thoughtful and self-confident—too young and too successful to feel burned-out or unhopeful. Described by hospital administrators as a rising star, he had been appointed the head of a ward only four years after completing his medical degree. Happy to speak to me as a colleague of sorts, he talked about the intellectual pleas- ure he had taken in working on the big clinical problems of psychiatry, such as schizophrenia. His decision to enter narcology was, like that of most other physicians, financially motivated. When I asked him about the forms of longer-term treatment offered to patients upon their departure from the hospital, Anton Denisovich explained, "Mainly it is khimzashchita—placebo therapy—or we orient them toward rehabilitation programs." By this point in my fieldwork, I knew that khimzashchita, which literally translates as a contraction of "chemical protection," referred to a treatment for alcoholism employing disulfiram, a drug that induces a heightened sensitivity to alcohol. I had also read in an English-language medical journal that Russian narcolo- gists sometimes used "placebo therapy" in their practice, but none of the physicians I had spoken to had mentioned it, and I was surprised at Anton Denisovich's depiction of disulfiram therapy in this way. "Can you explain khimzashchita?" I asked. "How should I explain it to you? As if you were a patient?" asked Anton Denisovich and then began without waiting for an answer: We inject the medication disulfiram. It comes in different forms: intra- venous, capsule form, or subdermal implantation. All of these forms are long-acting. If the medication is taken intravenously or orally, it dissolves in the stomach and ends up in the bloodstream and then enters the body's tissues, combines with proteins in the liver . . . and for a certain period of time this medicine remains in the bloodstream. This medication cannot be taken with alcohol, as it blocks the enzymes that break down alcohol. If a patient on this medication drinks and alcohol enters his bloodstream, the possible side effects are dangerous to his health or life-threatening. It can be anything from a flushing or reddening of the face to serious or crippling consequences or even death. . . . This is told to the patient and 214 KAIKHEL he signs a paper explaining that he understands the procedure. And then the procedure takes place. I was confused. "Then why is it 'placebo therapy'?" There was an awk- ward moment when Anton Denisovich hesitated, perhaps realizing that he was about to reveal a minor professional secret. "Well," he resumed, "because it is. . . . Because as you understand all patients cannot take these substances, in part because some of them won't wait out the entire period, and this would just be dangerous for them. So it's better to give him a placebo and give him the gift of several months of sober life, than to inject the real medication." He added that he treated some patients for as long as three years with this method, giving them yearly doses.12 This moment of doubt—when physicians assessed whether I already knew about placebo therapy, or what I knew—was reprised in many of my interviews. There were awkward pauses and pained glances; one narcologist insisted that the difference between using chemically active disulfiram and a neutral substance was merely a "professional nuance." Yet despite their hesitations, the narcologists did reveal to me their use of placebos, and their consequent deception patients. Of course they also justified their use of placebos, arguing—not without reason—that certain (noncompliant) patients could be harmed or killed by active disulfiram. I also learned that most medical reviews of disulfiram therapy empha- sized that when effective, it changed patients' behavior not by neuro- chemical means but through a psychological mechanism: "the threat or experience of an unpleasant reaction" (Brewer, Meyers, and Johnsen 2000: 329). Though certainly deceptive by North American standards of patient autonomy, giving patients such placebos was a way of harness- ing the treatment's potential effectiveness while minimizing the risk of harm from the drug. And yet, as I later listened to patients' accounts of the therapy, I felt uneasy about my knowledge. Their ideas about the potency of disulfi- ram covered a wide range. This is how Gleb, a middle-aged working- class man, described the risks of khimzashchita: "Before you take it you sign a paper saying that if you drink, the doctors are not responsible for what happens to you. . . . It's fine if it kills you: better that than it para- INSTITUTIONAL ENCOUNTERS 215 lyzing you or something. We don't know with these drugs. ... So each per- son needs to use his brain" (emphasis added). Yet for every account by a patient that seemed to reinforce the idea that khimzashchita was chemi- cally potent, there was another that attested to its ineffectiveness. Some patients recounted their own experiences surviving a drinking bout dur- ing their course of treatment as evidence for the chemical's lack of potency. Others swapped techniques for counteracting disulfiram's effects. Dmitri, a 12-step counselor, pointed to scars under his shoulder blades where the capsules had been implanted, and explained that dur- ing his hospitalizations other patients would tell him: '"Forget it, just drink a little lemon juice.' There were all of these means to counteract it that they'd give out right away, even while you were still in the ward, getting ready for the operation." While patients heard and circulated conflicting accounts about the chemical potency of khimzashchita, narcologists in the hospital worked to bolster its representation as a pharmacological treatment. When I asked Anton Denisovich whether he sometimes administered the actual chem- ical disulfiram, he responded, "You understand that we can't give every single person the placebo, because we'll discredit the method that way." Not only did his rejoinder indicate a widespread anxiety among narcol- ogists that placebo therapy could easily lose its effectiveness by "becom- ing discredited," but his statement was itself a speech act aimed at maintaining the legitimacy of the therapy. Whether "the real medica- tion" was ever used or not, it was important to tell this ethnographer that it was used at least sometimes, lest I depict the entire therapy as a sham, as others had done. institutions: the house To get to the House of Recovery, a center in the St. Petersburg area pro- viding free-of-charge rehabilitation for alcoholism, you have to travel half an hour by suburban train to a village on the city's outskirts. I first visited on a Sunday in January, and a crowd of downhill skiers disem- barked at the station; a slope had recently been opened nearby, attracting 2l6 RAIKHEL more visitors to the once sleepy station. From there the House is another forty-five minutes by foot (or longer in ankle-deep snow), past farm fields, traditionally styled Russian village houses, newer dachas, and sev- eral half-built mini-mansions. While the House's geographic location on the city's margins mirrors its position in the field of addiction medicine— compared with the Addiction Hospital's centrality—the material condi- tion of its building reflects its relative youth and modest prosperity: an unremarkable red-brick structure, newly constructed and well-kept. I had heard about the House of Recovery during an early visit to St. Petersburg, but it was in the United States that a colleague put me in touch with Ilya Vladimirovich, a Russian American psychiatrist who has played a key role in the House's foundation and operation. Prior to his emigration to the United States, Ilya Vladimirovich had worked for nearly a decade at the Bekhterev Psychoneurological Institute, one of the most respected centers for psychiatric research in the Soviet Union. In the early 1990s, he had been hired to manage the Russia-focused philan- thropic efforts of a former tobacco executive and supporter of Alcoholics Anonymous (AA).13 Early efforts had focused on bringing physicians and psychiatrists, clergymen and members of the cultural intelligentsia to the United States to tour rehabilitation centers (and in many cases to undergo treatment), with the aim of bolstering the stature and legitimacy of 12-step methods in Russia. By the mid-1990s, Ilya Vladimirovich and his American employer had developed a new strategy. Drawing on the Minnesota Model, a widely used 12-step-based protocol for inpatient substance abuse rehabilitation, they founded the House of Recovery (Spicer 1993). When I expressed interest in conducting research at the House of Recovery and made it clear that I was willing to make myself useful, Ilya Vladimirovich's response was enthusiastic. Since the money funding both the House and its clinical technologies flowed from the United States, there was a great deal of translation to be done in the manage- ment of the center, and I was soon working on English and Russian texts for reports, letters, brochures, and Web postings. At the same time I began regularly taking part in daily activities at the House. Unlike at the Addiction Hospital, there were no bureaucratic hurdles, no forms to fill INSTITUTIONAL ENCOUNTERS 217 out, no research contracts, no review of my project. In exchange for my work translating texts, the doors of the House were open: I was allowed to interview patients, join them for their lectures and conversations, and sit in on meetings with the counseling staff. The only restriction was that I was not allowed to sit in on group therapy or closed 12-step group meetings.14 In fact, here the limits to productive encounters were shaped not so much by bureaucratic exigencies as by my self-identification. While at the Addiction Hospital I had no choice but to temper my obvi- ous association with the staff, at the House of Recovery I found that I was always a potential fellow in recovery or an addict in denial. The practices of AA and other 12-step programs require specific kinds of self-identification from participants. One longtime substance abuse counselor in St. Petersburg told me that for him, self-identification as an addict was more than a prerequisite to rehabilitation: it was central to the entire process of the 12 steps. Not only does AA function as a technology of self-transformation, in which participants gradually learn to narrate their life histories in a way that enables them to self-identify as alcoholics or addicts, but it also encourages another sort of identification: that of individual members with one another through their common experi- ences (Rudy 1986:18-42; Denzin 1987: 74; Cain 1991). These two types of identification are linked: telling one's story at an AA meeting is at once a means for the speaker to narrate his or her experience and receive sup- port and also an opportunity for listeners—particularly new members— to reflect on their own common experiences.15 Like the American rehab centers on which it was modeled, the House of Recovery offered a program run primarily by recovering alcoholics and addicts. Some of the trained psychologists identified not as alcoholic but as codependent {sozavisimost'), a category that has entered Russia with the arrival of 12-step therapy. Originally a term from the 12-step movement that designated as an illness in its own right behavior by fam- ily members (typically wives) that supported or, in the language of the program, "enabled" others' alcoholism, codependency has entered the discourse of North American popular psychology as—in its more extreme forms—a pathologization of almost any social relationships that abrogate individual autonomy or rights (Haaken 1993; Borovoy 2001: 2l8 RAIKHEL 98). At the House codependency was a key category, ratifying the inclu- sion of a number of non-alcoholics into the therapeutic community. For instance, several members of the support staff, who at first had no partic- ular affinity for the program, had gradually learned the language and culture of the 12 steps and had begun to think of themselves as codepen- dent in the broad sense of the term (they did not have family members who abused alcohol). One had gone on to receive training as a substance abuse counselor. The category of codependency thus allowed members of the House community to constitute themselves as parts of a house- hold or family unit linked by experiences of dependence and recovery. Because mutual-help groups such as AA are—for the most part- restricted to people suffering from addiction (or at least those who believe that they "have a problem with alcohol"; Wilcox 1998: 48) and because their definition of those individuals is based largely on self- identification and self-ascription, they present a particular challenge for ethnographic research. Whereas several social positions are available for ethnographers to occupy in most clinical institutions, the legitimate options in groups such as AA are at once more limited and more flexi- ble.16 Moreover, the structure of AA meetings makes it very difficult for a visitor not to declare his or her relationship to the program, and thus almost impossible not to get "caught up in it," as Jeanne Favret-Saada writes of her fieldwork on witchcraft ir rural France (1990:191). Indeed, on my very first visit to the House I attended an open AA meeting, dur- ing which a visiting speaker presented his story of decline and recovery to the group. As we each introduced ourselves to the group, using the familiar formula—"Hello, I'm X and I'm an alcoholic"—I found I was the only person in the room to simply say, "Hello, I'm Eugene." Telling myself that a disingenuous identification would be patronizing to the House's patients and staff, I continued to introduce myself this way for a few months. However, several members of the House community persistently refused to accept my disavowal of alcoholism. Eduard was particularly insistent. A burly man with a wide and friendly face, Eduard had spent a decade of his life drinking heavily and barely holding down a series of short-term jobs. When he had finally been persuaded by relatives to go INSTITUTIONAL ENCOUNTERS 219 through treatment at the House of Recovery, Eduard was so taken with the program that he eventually became a substance abuse counselor. He presented himself as a simple guy and enjoyed gently poking fun at the House's supporters among "intellectuals and bohemians." On several occasions when we rode the train together, Eduard asked me why I had decided to study alcoholism. I explained as best I could, but found myself relying on what sounded like tired cliches (alcoholism repre- sented such a profound public health crisis in Russia, etc.), especially when compared to his firsthand experiences. As I spoke, I realized that I had never been asked this question at the Addiction Hospital. To be sure, the physicians there took for granted the importance of alcoholism as a "problem" in contemporary Russia, as did Eduard. What was strikingly different in these two fieldsites was how my interlocutors thought about the connections between personal expe- rience and research interests. At the hospital, the physicians treated me as a kind of colleague, an emissary of "international science." If researchers agreed that alcoholism was an important topic for study, there was no further reason to question my choice; whatever other motivations I might have had, they were extraneous and irrelevant to many of the nar- cologists. Eduard, in contrast, was asking (indirectly at first) whether my (conscious or unconscious) motivation for choosing to research alco- holism treatment was my own (presumably unacknowledged) addic- tion. I thought I recognized Eduard's intention because I had already been asked this question, in the same way—not in Russia but in the United States—before my fieldwork began. When I had told fellow anthropologists about my project, many ini- tially asked whether I had experienced alcoholism in my family. At the time, I had assumed that the impetus for these questions was specific to anthropology (and its neighboring disciplines). For anyone socialized into the assumptions of contemporary academic anthropology, the notion that our research interests are shaped by biographical particulari- ties has become something of a platitude. I was already, like many col- leagues of my generation, carrying out my first project in a place where I had familial ties, so it was perhaps easy to extrapolate a similar personal connection to my thematic focus. In the field, as I attempted to answer 220 RAIKHEL Eduard's questions, my colleagues' questions took on a slightly different meaning. It was not only the anthropological creed of reflexivity that made a link between one's life's work and one's personal experiences seem self-evident: the same presupposition was woven through the amalgam of self-help techniques and pop psychology that makes up much of the American therapeutic culture (Rieff 1987). More specifically, this idea testified to the influence that the 12-step movement has had on North American assumptions, as illustrated by the familiar figure of the recovering addict turned substance abuse counselor. However, Eduard's questions were forcing me to encounter this idea in unfamiliar territory. I was not mistaken about Eduard's intentions. After I collected his life story—over the course of several afternoons in his apartment—he con- fronted me directly: "Tell me, Eugene. Are you sure you don't have a problem?" There were many addictions, he explained; the dependence to which I was failing to own up wasn't necessarily on alcohol. I told him that no, everything was fine, he needn't be concerned; but I was irritated at his insistence. Over the following weeks, I increasingly felt that my behavior was being observed by people at the House and I found myself (in a reaction similar to the countertransference described by Leo Cole- man in chapter 5 of this volume) disavowing an addict identification more deliberately and vehemently than I had done before. At a dinner for the House of Recovery's American donors, I joined one other person at the table in ordering a glass of wine. Late in the spring I accompanied Eduard and several other counselors to a celebration for a nearby 12-step group. At the registration for the event, everyone was asked their "status"—the appropriate response being one's illness identity (alcoholic, drug addict) and one's period of sobriety (e.g., sober for two years). As I pondered an appropriate answer, Eduard stepped in to explain, "He's codependent." I had never thought of introducing myself this way, but by this point considering myself codependent was beginning to have a certain logic. Could not my field- work relationships with Eduard and others at the House of Recovery be understood in this way? I was, after all, getting pulled into relationships with my informants in ways I had not expected and I was reacting to their demands in ways that I judged (from the standpoint of an imagined INSTITUTIONAL ENCOUNTERS 221 ideal ethnographer) to be at best withdrawn and at worst dismissive. More importantly, the notion of identifying me as codependent meant something to Eduard and other members of the House community: it placed me in a legitimate and understandable category and relationship to them. (Somewhat more troubling was the implication that my interest in the House of Recovery, and my research itself, was pathological—that I was addicted to studying addicts and needed help.) Nevertheless, at the next open meeting I attended, I introduced myself as codependent. As I later learned, my ability to inhabit this category had its own very palpable limits. The major event of the summer was the House's anniver- sary celebration—an event complete with guest speakers and perform- ances by a folk music band and a clown-mime troupe. The anniversary drew hundreds of the House's alumni from all over Russia and several other post-Soviet states. It was also attended by the program's American sponsor, and I was given the job of translating conversations for him. Toward the end of the day my wife, Iris, who does not speak Russian, ges- tured for me to come near. She was being addressed by a small woman who was speaking very quickly in a mix of Russian and English. I should add that being American had a very particular meaning at the House of Recovery, where the United States was seen by many as the "motherland [rodina] of AA," as one counselor put it. The woman was explaining that her father had died recently and that she had subsequently learned that most of the men in her family had been alcoholics. She had become convinced, she explained, that the same would be true of any man she married; she felt she was somehow cursed. As I translated I slowly understood what was happening: the woman, assuming that my wife considered herself codependent, was asking for advice. What should she do? she asked. What would be the right thing to do in her situation? We made several very unhelpful attempts at advis- ing her, sheepishly suggesting that she speak to some of the others pres- ent at the celebration. The woman persisted, asking my wife again: What did she think of this problem? It was then that I blurted out that neither of us were alcoholics—that I was a researcher working with the center, and my wife had simply accom- panied me for my day of fieldwork. As I spoke, the woman slowly backed 222 RAIKHEL away, in mortified shock, saying, "But I thought everyone here was an alcoholic." We mumbled our embarrassed apologies, staring at our feet. anonymities: privacy commodified The space of safety and mutual understanding, which my wife and I had inadvertently punctured for this woman, was underpinned by two prin- ciples key to both AA and the House of Recovery. The first, as I have already discussed, was the self-identification of members as alcoholics or codependents and their identification with one another through com- mon experiences. The second principle was that of anonymity: specifi- cally, AA's practices of partial internal anonymity and full external anonymity. During the first years of the AA movement (in the 1930s and '40s), external anonymity was primarily a means of attracting members to the program by protecting their identities; as the movement grew it played an additional role in guiding members' dealings with people out- side of the program (Makela et al. 1995: 48-50). In addition to helping maintain an egalitarian ethos within the organization and reducing pos- sibilities for self-promotion, anonymity has also been important as a way of symbolically subordinating individuals to the group—or, in the lan- guage of the 12th Tradition, "plac[ing] principles before personalities" (Alcoholics Anonymous 1^53:184; see also Bateson 1971; Fainzang 1994: 342). Moreover, anonymity has a particular relationship to identification in the program, in that it is a condition of possibility for the confessional accounts that are central to the ritual of the AA meeting.17 At the House of Recovery, the regime of anonymity mediated a partic- ular set of power relations between patients and the counseling staff, which was somewhat different from the dynamic taking place in free- standing AA groups in the city. Whereas patients knew one another only by their first names and initials (unless they chose to disclose more), counselors knew patients' last names and would often mention them in staff meetings. However, although nearly all of the counselors were themselves recovering alcoholics—who would identify themselves only by the first name when they attended a regular AA meeting in St. Peters- INSTITUTIONAL ENCOUNTERS 223 burg—at the House they were known to patients by their first names and patronymics (e.g., Pavel Ivanovich). This style of address signifies for- mality and respect; when used by only one participant in a conversation, it is typically a sign of his or her deference in an asymmetrical power relationship (such as servant to master, student to teacher, or child to par- ent). These relationships were made material in the name badges that everyone—patients and staff alike—wore at the House. Thus while these practices provided for a level of anonymity that some patients—particu- larly employed professionals, policemen, and members of the federal security services—saw as important, they also contributed to many patients' conviction that they were being infantalized by counselors. Anonymity of a somewhat different variety had a place at the Addic- tion Hospital, in the form of what was called "anonymous treatment." This practice had its basis in the narcological register, a Soviet-era insti- tution that was essentially a list, kept by each district-level clinic and hospital, of patients diagnosed with a particular addiction. The register was a key element linking Soviet addiction treatment both to a residen- tially based system of urban governance and to the state's systems for medical surveillance and control.18 Patients on the register were prohib- ited from receiving a gun permit or a driver's license; from working in a number of occupations, and from traveling abroad. Once placed on the register, a name remained there for three years. In short, the register was meant to keep addicts away from potentially dangerous situations; at the same time, the threat of appearing on it was intended to deter potential alcoholics (Tkachevskii 1974; Gilinskii and Zobnev 1998). During the post-Soviet period, state and municipal clinics treating addiction began to offer patients the possibility of treatment without being placed on the register, for a price (Galkin 1996). This became the legally sanctioned practice of every clinic in the municipal network in St. Petersburg. Part of its justification was that similar "anonymous" services were already available in commercial clinics. Since the laws barring those on the register from owning guns or receiving driver's licenses remained unchanged, the result was the creation of a two-tier system, with very dif- ferent degrees of state surveillance. Treatment was nominally free of charge for those who would accept having their names on the register, 224 RAIKHEL while others, who paid, could escape the penalties and restrictions. From the point of view of some physicians and public health reformers, this system served to further penalize the socially marginalized and poor. Others pointed out that the practices of "anonymity" made it more diffi- cult to hold physicians legally accountable for their actions. Even those physicians who defended the practice did so in a guilty tone, insisting that "anonymous treatment" simply capitalized on a (now- unjustified) suspicion that some patients had of the state service. For instance, the administrator Grigorii Mikhailovich assured me that the confidentiality of patients' records and doctor-patient privilege was guar- anteed by the sixty-first article of the 1993 General Law on Health Care of the Russian Federation (Tsyboulsky 2001: 259; see also Tichtchenko and Yudin 2000: 230). Nevertheless, he explained, "The fear that someone will tell someone or get the information—this still lives." Thus the Addiction Hospital provided the service of anonymous treatment, which was "eas- ier for [the patients], and easier for us, because we get extra money," he added laughing. Yet in the same breath Grigorii Mikhailovich recounted recent attempts by police to access the register, undercutting his argument that confidentiality is secured by a new post-Soviet legal regime: "Just before the three hundredth anniversary [of St. Petersburg], I was sending away policemen.... One of them wrote to me saying, 'Give us the lists of the people who have been treated here.' And I replied ... 'You won't get any lists.'" Deliberately or not, Grigorii Mikhailovich's account laid bare the institutional incentives for narcologists to stoke fears of such unscrupu- lous policemen, thereby bolstering the "need" for anonymous treatment. Grigorii Mikhailovich acknowledged that the current demand for anonymous treatment grew partly out of the punitive character of the Soviet system; in his view, "This is what the anonymous treatment is connected to: the fact that there was this punitive system." Yet it was in the interest of physicians like Grigorii Mikhailovich to perpetuate the notion that the confidentiality of patients' records was still not secure. In other words, in order for narcologists to create a demand for anonymous service, patients had to be continually reminded that their information might fall into the wrong hands and led to fear that legal protections of INSTITUTIONAL ENCOUNTERS 225 confidentiality and doctor-patient privilege were weak.19 Given the lack of institutional protections for privacy during the Soviet period and the continued vulnerability of personal information to theft or sale during post-Soviet years, it was not difficult to convince patients of the need for anonymous service.20 Though the prices that the narcologists I spoke to named for this serv- ice were relatively modest, there was clearly significant money to be made. In fact, revenue from the anonymous treatment of drug addicts had played a part in inciting the conflict that resulted in the murder of the hospital administrator.21 I found the murder difficult to write about. Despite my efforts to squeeze it into footnotes, it dominated my narratives of fieldwork, threatening to overwhelm everything else. In the simplest terms, it was, like the com- mon practices involving the deception of patients and anonymous treat- ment, an index of unsteady ethical regimes, uneven state regulation, and a highly commercialized medical sphere. However, it also raised the question of what it had meant to conduct fieldwork in such an institu- tional site. As I wrote my accounts of fieldwork, this tragedy made painfully clear the necessity of taking my own measures to ensure the anonymity of my informants. But what about my research topic? Had a year of fieldwork been nec- essary to learn something about addiction and its treatment in Russia? I have suggested that as institutional spaces that I experienced through my encounters with physicians, patients, counselors, and administra- tors, the Municipal Addiction Hospital and the House of Recovery were instantiations of strikingly different ideas about illness and addiction. Not only were these ideas inscribed into clinical techniques and material spaces, they were, at least to some degree, implicit in the ways I and my motivations were identified by my interlocutors and in the ways these identifications circumscribed the possibilities for encounters in the field. For instance, while his persistent questions bothered me, Eduard had every reason to consider the possibility of my being an addict in denial. 226 RAIKHEL The logic of his assumption became particularly clear as I shuttled between the two fieldsites. To put it in overly simplified terms, at the Addiction Hospital, the identification of alcoholism was an act of diag- nosis carried out by physicians. At the House of Recovery, it was an act of self-identification carried out by participants. For physicians at the hospital, alcoholism was a disease ep'istemologically accessible through particular symptoms—some self-reported, some visible to the physician. One narcologist at the hospital explained to me that she could typically see the ravages of long-term alcohol use on the bodies of patients. "You, for instance/' she added. "It is clear that you are not an alcoholic." This reliance on visual cues and physical markers of illness has a basis in a neurophysiological style of reasoning long dominant in Russian psychi- atry, and in an overwhelmingly biological understanding of alcoholism. It was also a simple reading of my middle-class American habitus: it was clear that I wasn't an alcoholic, because I didn't look like one. At the House, the experience of fellow suffering was valued over professional expertise; anyone could and might be an addict.22 The notion of code- pendence expanded this field of possible identifications even further, although it was a category with certain limits and one that I found myself unable to successfully inhabit, despite my own attempts and the efforts of my acquaintances. Learning something about these starkly contrasting conceptions of alcoholism was not simply a matter of interpreting texts and statements made by my interlocutors, although these certainly were necessary sources. Equally important were what Jeanne Favret-Saada has called "situations of involuntary and unintentional communication," which "although they are commonplace and recurrent [during fieldwork], are never taken into consideration for what they are: the 'information' they have brought to the ethnographer appears in the text, but without any reference to the affective intensity which went with it in reality" (1991: 195). That such situations are just as "commonplace and recurrent" in clinics, laboratories, and offices, where fieldwork is increasingly carried out, as they are elsewhere is a point that would be too self-evident to belabor, were it not for the perception that these spaces, so redolent of modernity and ostensibly so homogeneous, threaten the productive INSTITUTIONAL ENCOUNTERS 227 ambiguity and uncertainty central to the production of ethnographic knowledge. Part of the methodological challenge of working in such set- tings is not only maintaining a sense of unfamiliarity but also remaining open to learning something from the (sometimes profound) failures of identification. notes This chapter has benefited greatly from the readings and suggestions of John Borneman, Leo Coleman, Daniel Alexandrov, Kelly McKinney, Alessandra Miklavcic, Roger Schoenman, Iris Bernblum, and three anonymous review- ers. Earlier versions of some of the chapter's contents were also shaped by the insights of Joao Biehl, Carol Greenhouse, and Stephen Kotkin. The field- work described in this chapter was generously funded by a Fulbright-Hays Doctoral Dissertation Research Abroad Fellowship. 1. On August 26, 2004, the deputy director of the Municipal Addiction Hospital, Larisa Artyukhovskaia, was killed by a bomb that had been left at the doorway to her apartment. The discovery of a similar remote-controlled device near Sergei Tikhomirov's apartment led the procurator's office to initiate a broad investigation into the conflicts over control over the narcology business in the city; Tikhomirov's arrest followed in early October. Reports differed on whether Artyu- khovskaia, who was in charge of the hospital's finances, had refused to participate in Tikhomirov's business or had simply refused to share in the profits she herself stole from the hospital (see Andreev 2004; Bezrukova 2006). Notably, this was not an isolated incident of deadly violence in the St. Petersburg narcological sphere. Tikhomirov's prede- cessor as head narcologist for the Northwest Federal District had resigned after being attacked on the street and severely beaten several times, and a candidate for a deputy post had been attacked by an acid- wielding assailant before she could assume her position (Tumakova 2004). In October 2006, some two years after Tikhomirov's arrest, St. Petersburg's chief children's narcologist, Vyacheslav Revzin, died after being beaten by a gang of unknown assailants. Several days later, Ivan Shvets, the director of a outpatient municipal narcological dispensary, was found dead in an apparent suicide (Stolyarova 2.006). 2. In a set of observations that can be generalized to other clinical settings/Van der Geest and Finkler (2004: 1995) note the widespread 228 RAIKHEL perception of hospitals as spaces where the practices of contemporary biomedicine are conducted and reproduced in a relatively uniform manner, regardless of local context. However, as work conducted on the anthropology of biomedicine over the past twenty-five years has shown, this perception of uniformity and relative homogeneity is bet- i ter understood as the ideology of biomedicine. 3. OED Online, s.v. "identification," http://dictionary.oed.com/cgi/ entry/50111211 (accessed February 18, 2008). 4. All translations from the Russian (unless otherwise indicated) are mine. Cyrillic letters have been Romanized using the Library of Con- gress transliteration table, with the exception of proper nouns with commonly accepted English spellings (e.g., Vasilievsky Island). 5. On the Soviet social hygiene movement, see Susan Solomon (1989). On the development of the narcological system, see Babayan and Gonopolsky (1985); Gilinskii and Zobnev (1998: 117-23); see also the accounts in Connor (1972); Peter Solomon (1978: 83-88). 6. Most of the names used in this essay are pseudonyms. In order to simply demarcate the roles of different informants, I use first names (such as Vyacheslav or Pavel) to indicate patients and 12-step coun- selors and first names along with patronymics (Anton Denisovich, Alexander Sergeevich) to mark most physicians. Because the first name/patronymic combination is a relatively formal type of address, typically used to mark respect or social distance in Russian, its use runs the risk of essentializing the distinction between physicians and patients; but this naming system also gives a sense of the interpersonal hierarchy at play in most St. Petersburg clinics. I have used the actual names of those few figures who have already been written about in the media; they are identified by their first and last names (e.g., Sergei Tikhomirov). 7. Interestingly, early 1990s efforts at problematizing the category of "native anthropologist" paid little attention to the role of language— specifically, fluency and accent—as an important factor shaping ethno- graphers' positionality in fieldwork encounters (Abu-Lughod 1991; Narayan 1993). 8. In describing his experiences conducting research in a Bangladeshi hospital, Zaman (2008: 147) points to the trade-offs of being a physi- cian-anthropologist: the relative ease of gaining the trust of fellow doc- tors and some patients versus the occasional difficulty of asking "naive" questions. Unlike Didier Fassin, Paul Farmer, Arthur Klein- man, Laurence Kirmayer, and other physician-anthropologists who have written about their clinical work, Zaman explains that he was not INSTITUTIONAL ENCOUNTERS 229 a practicing physician in the hospital where he carried out his field- work, and thus presented a somewhat ambiguous figure to patients. 9. Interestingly, other patients did question the veracity of the pseudo- patients' diagnoses, some even suspecting them to be journalists or researchers (Rosenhan 1973: 252). For a critique of the experiment in "pseudopatient diagnosis," see Spitzer (1975); see Slater (2004) and Spitzer, Lilienfeld, and Miller (2005) for a recent resurrection of this debate. Thanks to Allan Young for bringing my attention to these studies. 10. Of course, such concerns are hardly exclusive to ethnographers work- ing in post-socialist settings. See Lederman (2006) and the other arti- cles that appeared in the special issue of American Ethnologist devoted to institutional review boards and ethnography. 11. Given physicians' generally high level of authority in the hospital, in relation to patients, this selection of interviewees led me to question patients' capacity to give consent under such conditions. See Vieda Skultans's discussion of a similar quandary during her fieldwork with psychiatrists and their patients in Latvia (2005: 496). 12. Disulfiram is used throughout the world as an adjunct therapy for alcoholism. As Anton Denisovich noted, it prevents the body from fully processing alcohol: by blocking the action of a key enzyme in the metabolic pathway of ethanol, the drug causes a buildup of the toxic by-product acetaldehyde, with extremely unpleasant consequences for patients. Rather than experience the pleasure and elation of alcohol intoxication, people with active disulfiram in their bodies become flushed and nauseated upon drinking. Disulfiram began to be used by Soviet physicians soon after its introduction, and by the 1980s it was one of the most popular therapies among patients and their relatives. The replacement of disulfiram with neutral substances also became widespread during this time (see Fleming et al. 1994; Mann 2004). 13. Because the organizational autonomy of individual groups is one of the central principles of AA, there is no single narrative of the program's foundation in the former Soviet Union. Nevertheless, though groups formed in different cities under somewhat different circumstances, cer- tain broad conditions allowed for the introduction and development of AA. The earliest groups, which formed during the mid-perestroika period, were facilitated not only by the increasing tolerance shown by the state toward nongovernmental organizations but by the Soviet anti- alcohol campaign that was then under way (White 1996). For instance, a series of joint Soviet-U.S. conferences on alcoholism that began in 1987 brought experts on addiction from the United States to the Soviet Union. Among them were officials representing the General Service Office of 23O RAIKHEL AA in New York and the Reverend J. W. Canty, an Episcopal priest who worked to promote AA in the Soviet Union. These meetings led to the establishment of early groups such as the "New Beginners" in Moscow in 1987 and "Almaz" in Leningrad soon after (Burke 1990). Starting in the late 1980s and continuing through the 1990s, a steady stream of U.S.- based AA missionaries visited the Soviet Union and, later, Russia. No surveys of AA in Russia have been conducted (and the informal nature of the organizations make this a difficult proposition), but by the time of my research there were at least 10 A A groups in St. Peters- burg with more than 150 members, at least 30 groups in Moscow, and, according to some estimates, as many as 300 groups throughout the Russian Federation (Critchlow 2000a, 2000b). Large cities such as Nizhni Novgorod and Kazan had multiple groups, and AA members were active as well in small cities in European Russia such as Kostroma and Ivanovo. Other 12-step-based mutual-help groups, such as Narcotics Anonymous, Gamblers Anonymous, and groups for code- pendent family members such as Al-Anon, were also becoming increasingly popular in larger cities. 14. Although anyone is allowed to attend AA meetings designated "open," "closed" meetings are restricted to those who are already members or believe they "have a problem with alcohol" (Wilcox 1998: 48). 15. There are of course many varying interpretations of the processes cen- tral to healing and self-transformation in AA and other 12-step pro- grams. For the purposes of this argument, it is worth noting that many participants—unlike the counselor mentioned above—may not view identification as an important element in the program, focusing instead on the values of humility or surrender or the modest tech- niques for living, such as "one day at a time" (Valverde 1998:135-37; Wilcox 1998: 83-107). Indeed, Mariana Valverde argues that AA includes two distinct forms of self-governance, which are continually in tension with one another: a "theory of alcoholism as a disease [, which] fits the familiar Foucaulrian pattern of identity-based gover- nance," and a set of pragmatic techniques for maintaining sobriety, which "constitute a cobbled-together, low-theory, unsystematic system for habit reform" (1998: 140). Others have interpreted the transforma- tive aspects of AAin much less gradualistic terms as a "spiritual awak- ening" modeled on Protestant theology (Antze 1987: 173), or as a radical epistemological shift away from a pathological Cartesian dual- ism (Bateson 1971). 16. Many researchers—myself included—have dealt with this issue by attending open meetings and conducting in-depth conversations or INSTITUTIONAL ENCOUNTERS 23I interviews with group members outside of the group setting (Makela et al. 1996; Valverde 1998). David Rudy represented himself to the members of AA groups he attended for sixteen months not as an alco- holic but as a "sociologist interested in finding out about AA," and gradually progressed from being viewed as "a tolerated intruder, an outsider, to a near-member" (1986: 2,3). Members of the AA group that Stanley Brandes studied in Mexico City allowed him to participate in meetings although he did not identify as an alcoholic, categorizing him as an "Admirer of Alcoholics Anonymous" (AAA) (2002: xv). On the other hand, Danny Wilcox was drawn to conduct an ethnography of AA only after a period of having experienced it as a recovering alco- holic (1998: 20-29). See also O'Halloran (2003). 17. For an interesting contrasting case, see Sylvie Fainzang's account (1994) of the French sobriety movement Vie Libre, which rejects anonymity, seeing it as a sign of a moral—rather than a medical—understanding of alcoholism. Arguing that anonymity often signifies the liminal stage in rituals of identity, Fainzang notes that while Vie Libre associates mem- bership into the group with the assumption of a new identity as an ex- alcoholic, AA members stay at this liminal phase, remaining anonymous just as they remain alcoholics, even when in recovery (1994:344). 18. Like other medical services, treatments for addiction were provided by local dispensaries as determined by an individual's propiska, a docu- ment that combined the functions of a residence permit with those of an internal passport. The propiska system—originally a Tsarist technol- ogy of internal passports, revived in 1933—was, and continues to be, a means by which the state attempted to control urban in-migration (Popov 1995; Hojdestrand 2004). (Of course, this system gave rise to a brisk market in permits, as well as to fictitious marriages arranged to obtain them, well before the post-Soviet period.) The link between the register and this residency system, by means of the local dispensaries, provided a grid through which state actors attempted to manage the health of populations. 19. The lack of protection of privacy was linked to a number of concrete factors, including the conduct of medical consultations. Vieda Skultans writes that in Soviet Latvia, psychiatric consultations "lacked the pri- vacy with which they are associated in the West. Access to consulting rooms is seldom restricted to a doctor and her patient. Besides the pre- scribing nurse who shares the consulting room, other staff and, indeed, patients frequently interrupt an ongoing consultation. . . . Patients were, until recently, in charge of their own notes. In such contexts, problems are publicly shared" (2005: 498). 232 RAIKHEL 20. Many thanks to Daniel Alexandrov for suggesting this interpretation of anonymous treatment and the register. 21. At the time of the murder, Tikhomirov concurrently occupied two posts: in addition to being the Addiction Hospital's director, he had, since mid-2003, been head narcologist for the Northwest Federal Dis- trict (okrug). According to news reports of the police investigation, Tikhomirov had developed a particularly lucrative business on the basis of his position as the Northwest District's head narcologist. One of his duties in this position was the licensing of commercial narcology clinics (for the treatment of alcoholism), a service for which he appar- ently charged approximately $2,000 (Andreev 2004). 22. The tensions between these ideas about alcoholism were played out in disputes over the appropriateness of AA for Russia. With its require- ment that physicians participate on par with other members, if at all, AA struck some narcologists as a threat to their professional status, and some leading narcologists argued against it precisely in these terms. For instance, a prominent narcologist dismissed AA in a news- paper interview as "anonymous brotherhoods, where there are no doc- tors, as 'only a drug addict will help another drug addict.'" "In that case," he asked, in an aside that infuriated many local AA members, should we say that only "a schizophrenia patient will help another schizophrenia patient?" (Dyleva 2004:11). references \bu-Lughod, Lila. 1991. "Writing against Culture." In Recapturing Anthropology: Working in the Present, ed. Richard G. Fox. Santa Fe, NM: School of American Research Press; dist. by University of Washington Press. dcoholics Anonymous. 1953. Twelve Steps and Twelve Traditions. New York: Alcoholics Anonymous World Services. ndreev, Sergei. 2004. "Glavnyi narkolog ubival kolleg?" [Did the head narcol- ogist kill his colleagues?]. Smena, October 7; http://smena.ru/criminal/332/ (accessed on April 4,2006). ntze, Paul. 1987. "Symbolic Action in Alcoholics Anonymous." In Constructive Drinking: Perspectives on Drink from Anthropology, ed. Mary Douglas. Cam- bridge: Cambridge University Press; Paris: Editions de la Maison des sci- ences de i'homme. bayan, Eduard A., and M. H. Gonopolsky. 1985. Textbook on Alcoholism and Drug Abuse in the Soviet Union. Trans. V. Bobrov. New York: International Universities Press. INSTITUTIONAL ENCOUNTERS 333 Balabanova, Dina, Jane Falkingham, and Martin McKee. 2003. "Winners and Losers: Expansion of Insurance Coverage in Russia in the 1990s." American Journal of Public Health 93(12): 2124-30. Bateson, Gregory. 1971. "The Cybernetics of 'Self': A Theory of Alcoholism." Psychiatry 34:1-18. Beliaev, V. P., and L. N. Lezhepetsova. 1977. "Opyt organizatsii narkologich- eskoi sluzhby v Leningrade" [The experience of organizing the narcological service in Leningrad]. In Lechenie i reabilitatsiia bol'nykh alkogolizma [Treatment and rehabilitation for alcoholism patients], ed. I. V. Bokii and R. A. Zachepitskogo. Leningrad: Bekhterev Institute. Bezrukova, Lyudmilla. 2006. "Narcolog-Ubiitsa" [Narcologist killer]. Trud 48 (March 21); http://info.trud.ru/trud.php?Id==20o6o32i048o502 (accessed April 4,2006). Bloch, Sidney, and Paul Chodoff, eds. 1991. Psychiatric Ethics. 2nd ed. Oxford: Oxford University Press. Borovoy, Amy. 2001. "Recovering from Codependence in Japan." American Eth- nologist 28(1): 94-118. Brandes, Stanley H. 2002. Staying Sober in Mexico City. Austin: University of Texas Press. Brewer, Colin, Robert J. Meyers, and Jon Johnsen. 2000. "Does Disulfiram Help to Prevent Relapse in Alcohol Abuse?" CNS Drugs 14(5): 329-41. Burke, Justin. 1990. "AA Marks Third Year in Soviet Union." Christian Science Monitor, November 20, p. 15. Cain, Carole. 1991. "Personal Stories: Identity Acquisition and Self- Understanding in Alcoholics Anonymous." Ethos 19(2): 210-53. Connor, Walter D. 1972. Deviance in Soviet Society: Crime, Delinquency, and Alco- holism. New York: Columbia University Press. Critchlow, Patricia. 2000a. "First Steps: AA and Alcoholism in Russia." Current History 99: 345~49- -. 2000b. "The Impact of Sociopolitical Change Since 1991 on Alcohol Treatment in Russia." Master's in Liberal Arts thesis, Harvard University. Denzin, Norman K. 1987. The Alcoholic Self. Sage Publications. Dyleva, Evgeniia. 2004. "Vodka s semenami konopli pressuet molodezhnuiu subkul'turu" [Vodka with cannabis seeds puts pressure on youth subcul- ture]. Peterburskii Chas Pik 26(336) (July 23-29): 11. Entin, G. M., A. G. Gofman, A. V. Grazhenskii, E. N. Krylov, A. Yu. Magalif, I. A. Nosatovskii, and I. V. Yashkina. 1997. "O sovremennom sostaianii narkologicheskoi pomoshchi v Rossii" [On the contemporary state of narcological help in Russia]. Voprosy Narkologii 1: 68-76. Estroff, Sue E. 1981.. Mafo'ng It Crazy: An Ethnography of Psychiatric Clients in an American Community. Berkeley: University of California Press. RAIKHEL Fainzang, Sylvie. 1994. "When Alcoholics Are Not Anonymous." Medical Anthropology Quarterly 8: 336-45. Favret-Saada, Jeanne. 1990. "About Participation." Culture, Medicine and Psychia- try 14(2): 189-99. 5ield, Mark. 1991. "The Hybrid Profession: Soviet Medicine." In Professions and the State: Expertise and Autonomy in the Soviet Union and Eastern Europe, ed. Anthony Jones. Philadelphia: Temple University Press. 'leming, Philip, A. Meyroyan, and I. Klimova. 1994. "Alcohol Treatment Ser- vices in Russia: A Worsening Crisis." Alcohol and Alcoholism 29(4): 357-62. 3alkin, V. A. 1996. "Sovremenye zadachi narkologicheskoi sluzhby" [Contem- porary objectives of the narcological service]. Voprosy Narkologii 1: 71-75. jilinskii, Yakov, and Vladimir Zobnev. 1998. "The Drug Treatment System in Russia: Past and Present, Problems and Prospects." In Drug Treatment Sys- tems in an International Perspective: Drugs, Demons, and Delinquents, ed. Har- ald Klingemann and Geoffrey Hunt. Thousand Oaks, CA: Sage. Hoffman, Erving. 1962. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Chicago: Aldine. ioldman, A. R., R. H. Bohr, and T. A. Steinberg. 1970. "On Posing as Mental Patients: Reminiscences and Recommendations." Professional Psychology 1: 427-34- laaken, Janice. 1993. "From Al-Anon to ACOA: Codependence and the Recon- struction of Caregiving." Signs 18(2): 321-45. lojdestrand, Tova. 2003. "The Soviet-Russian Production of Homelessness: Propiska, Housing, Privatization." Anthrobase; wvw.anthrobase.eom/Txt/H/ HoejdestrandT01.htm (accessed April 2, 2006). ozlov, Andrei, Alia Shaboltas, Olga Toussova, Sergei Verevochkin, Benoit Masse, Tom Perdue, Geetha Beauchamp, Wayne Sheldon, William Miller, Robert Heimer, Robert Ryder, and Irving Hoffman. 2006. "HIV Incidence and Factors Associated with HIV Acquisition among Injection Drug Users in St. Petersburg, Russia." AIDS 20(6): 901-6. aderman, Rena. 2006. "The Perils of Working at Home: IRB 'Mission Creep' as Context and Content for an Ethnography of Disciplinary Knowledges." American Ethnologist 33(4): 482-91. ncoln, W. Bruce. 2001. Sunlight at Midnight: St. Petersburg and the Rise of Mod- ern Russia. New York: Basic Books. akela, Klaus, et al. 1996. Alcoholics Anonymous as a Mutual-Help Movement: A Study in Eight Societies. Madison: University of Wisconsin Press. ann, Karl. 2004. "Pharmacotherapy of Alcohol Dependence: A Review of the Clinical Data." CNS Drugs 18(8): 485-504. arayan, Kirin. 1993. "How Native Is a 'Native' Anthropologist?" American Anthropologist 95(3): 671-86. INSTITUTIONAL ENCOUNTERS 235 O'Halloran, Sean. 2003. "Participant Observation of Alcoholics Anonymous: Contrasting Roles of the Ethnographer and Ethnomethodologist." Qualitative Report 8: 81-99. Popov, V. P. 1995. "Pasportnaia sistema v SSSR (1932-1976)." [The passport sys- tem in the USSR]. Sotsiologicheskie Issledovania 8: 3-14. Rhodes, Lorna A. 1991. Emptying Beds: The Work of an Emergency Psychiatric Unit. Berkeley: University of California Press. Rieff, Philip. 1987. The Triumph of the Therapeutic: Uses of Faith after Freud. New ed. Chicago: University of Chicago Press. Rivkin-Fish, Michele R. 2005. Women's Health in Post-Soviet Russia: The Politics of Intervention. Bloomington: Indiana University Press. Rosenhan, David L. 1973. "On Being Sane in Insane Places." Science 179: 250-58. Rudy, David. 1986. Becoming Alcoholic: Alcoholics Anonymous and the Reality of Alcoholism. Carbondale: Southern Illinois University Press. Segal, Boris M. 1990. The Drunken Society: Alcohol Abuse and Alcoholism in the Soviet Union: A Comparative Study. New York: Hippocrene Books. Skultans, Vieda. 2005. "Varieties of Deception and Distrust: Moral Dilemmas in the Ethnography of Psychiatry." Health 9: 491. Slater, Lauren. 2004. Opening Skinner's Box: Great Psychological Experiments of the Twentieth Century. New York: Norton. Solomon, Peter. 1978. Soviet Criminologists and Criminal Policy: Specialists in Policy-making. London: Macmillan. Solomon, Susan Gross. 1989. "David and Goliath in Soviet Public Health: The Rivalry of Social Hygienists and Psychiatrists for Authority over the Bytovoi Alcoholic." Soviet Studies 41(2): 254-75. Spicer, Jerry. 1993. The Minnesota Model: The Evolution of the Multidisciplinary Approach to Addiction Recovery. Center City, MN: Hazelden Educational Materials. Spitzer, Robert L. 1975. "On Pseudoscience in Science, Logic in Remission, and Psychiatric Diagnosis: A Critique of Rosenhan." Journal of Abnormal Psychol- ogy 84(5): 442-52- Spitzer, Robert L., Scott O. Lilienfeld, and Michael B. Miller. 2005. "Rosenhan Revisited: The Scientific Credibility of Lauren Slater's Pseudopatient Diag- nosis Study." Journal of Nervous and Mental Disease 193: 734~39- Stolyarova, Galina. 2006. "Second Drugs Expert Dies within a Week." St. Peters- burg Times, October 24; www.sptimes/ru/index.php?action_id=2&story_id= 19248 (accessed June 25, 2008). Tichtchenko, Pavel D., and Boris G. Yudin. 2000. "Toward a Bioethics in Post- Communist Russia." In Cross-Cultural Perspectives in Medical Ethics, ed. Robert M. Veatch. Sudbury, MA: Jones and Bartlett. 236 RAIKHEL Tkachevskii, IU. 1974. Pravovye mery bor'by s p'ianstvom [Legal measures in the battle with drunkenness]. Moscow: Izd-vo Moskovskogo universiteta. Tsyboulsky, Vadim B. 2001. "Patient's Rights in Russia." European Journal of Health Law 8(3): 257-63. Twigg, Judyth L. 1998. "Balancing the State and the Market: Russia's Adoption of Obligatory Medical Insurance." Europe-Asia Studies 50(4): 583-602. Valverde, Mariana. 1998. Diseases of the Will: Alcohol and the Dilemmas of Freedom. Cambridge: Cambridge University Press. Van der Geest, Sjaak, and Kaja Finkler. 2004. "Hospital Ethnography: Introduc- tion." Social Science & Medicine 59(10): 1995-2001. Van der Geest, Sjaak, and Samuel Sarkodie. 1998. "The Fake Patient: A Research Experiment in a Ghanaian Hospital." Social Science & Medicine 47(9): 1373-81. White, Stephen. 1996. Russia Goes Dry: Alcohol, State and Society. Cambridge: Cambridge University Press. Wilcox, Danny M. 1998. Alcoholic Thinking: Language, Culture, and Belief in Alco- holics Anonymous. Westport, CT: Praeger/Greenwood. Zaman, Shahaduz. 2008. "Native among the Natives: Physician Anthropologist Doing Hospital Ethnography at Home." Journal of Contemporary Ethnography 37:135-54-