Methadone Maintenance Treatment: Biological Citizenship

2015

It is here that the work of Nikolas Rose () becomes particularly useful, in its analysis of the ways in which contemporary negotiations of medicine co-produce new forms of responsibility and obligation, as well as new kinds of social action and claim-making. Rose and Carlos Novas (2005) refer to ‘biological citizenship’ to describe specific instances of this. Making up biological citizens refers both to changes in the means by which medical, legal and other authorities understand people and those in which people have come to understand and produce narratives of themselves. Identity categories such as ‘the chronically sick, the disabled, the blind, the deaf, the child abuser, the psychopath’ now organise the ways in which groups of people are regulated by experts. Equally, biological citizenship describes the creation of persons with a certain kind of relation to themselves. These citizens use biologically inflected language in narrating their own experience and subjectivities:

For example, they describe themselves as having high levels of blood cholesterol, as vulnerable to stress, as being immuno-compromised, or as having an hereditary disposition to breast cancer or schizophrenia.

(Rose and Novas, 2005: 12)

They may also organise collectively to advocate for change based on these relations to themselves and domains of medical diagnosis and treatment.

Hacking and Rose have made significant contributions to an extensive body of work on medicine as an important force in the production and regulation of contemporary subjects in liberal societies (). Hacking’s work illuminates the profound changes wrought by the interplay between classification and classified. Rose’s account of biological citizenship emphasises that the agency of medical patients brings about changes not only to medical classification but also to social identities and networks, and to the ways in which claims are made on the state. methadone maintenance treatment, a medical response to addiction freighted with many of the criminal and political meanings attached to drugs and addicts, is productively studied using both.

There are two ready examples of methadone’s productivity in forming treatment identities. The first is liquid handcuffs. As we saw in Substitution, Metaphor and Authenticity, this is a dominant metaphor for methadone, and is used internationally by clients and service providers. Given the emphasis in contemporary critical understandings of power on its internalisation and productivity, it is important to note that methadone also invokes responses to power in a much more externalised sense of the term. When clients use a term like ‘liquid handcuffs’ they also describe themselves as prisoners, constrained by methadone and by the treatment regimes: a point to which we return in Repetition and Rupture: The Gender of Agency. The second example comes from the precrip-tiveness around socialisation and re-education in our interviews and in policy documents. Indeed, the openness with which moral prescriptions around behaviour and discipline are delivered is a striking feature of medico-legal drugs rhetoric (). In some ways it is not the subtext that clients are infantilised, deviant and in need of moral education, but the text. This is illustrated by Barry, who works in policy and is a doctor.

I suppose that there’s a certain paradox that they [clients] feel that they are being treated like children and criminals, and yet the medical profession is saying one of the wonderful things about medical-ising drug and alcohol is of course that we take away from the model of the judgmental and the criminal. But actually in practice, we actually do treat them as untrustworthy children.

(Barry, Sydney, NSW, policy/prescriber, 40)

This paternalism can also be read as explicit, visible power that makes use of metaphor and analogy. Alongside our investigations of how methadone maintenance treatment works to change the terms by which people understand themselves and the empirical categories through which the world is ordered, we also need to consider the effect and uses of existing categories. Liquid handcuffs and errant children: these are examples of the circulation and re-animation of existing repertoires and of the circuitous, recursive effects of language on experience and experience on language. A phrase by which methadone has long been known to clients and service providers represents a shared language to describe a shared experience, and its repeated use informs and shapes experience. Similarly, the infantilisation of drug users is reproduced and embedded in treatment, at once shaping the expectations of experts and deployed as a tool to confirm those expectations. Both obtain through their availability as repertoires and their experiential ‘fit’. Expectations are formed by available repertoires and inform the experience that clients and experts have of treatment, which then is recirculated through these repertoires. As we saw in The Chronotope of the Queue, expectations around the malign agency of clients materialise the layout of clinics, and Repetition and Rupture: The Gender of Agency shows that expectations around gender inform treatment decisions.

In some ways, this is quite a mundane point: people constitute their experiences of drug treatment (of addiction, of clinical practice, of anything) through the language that is available. However, there are a couple of stronger claims to make from it. The first is a reiteration of the argument made in Substitution, Metaphor and Authenticity that language does not only describe experience, but also shapes it. The metaphors and analogies that circulate through the world of methadone maintenance treatment have more than descriptive power. The second is that these available categories confirm and embed some of the more pernicious effects of treatment. As we argue throughout this book, many clients do experience methadone as repressive and are constrained by restrictions on their movement, time and privacy. Many service providers do view clients as asocial and deviant, in need of surveillance and discipline. These repertoires work towards reproducing the effects of treatment that other repertoires, such as value-neutral policy language, can mask.

As we argue throughout this book, existing identity categories are very important to the production of treatment. The focus of this post, however, is the effects of methadone maintenance treatment in producing new kinds of identities. In making a claim for new identities, we are not arguing that we have discovered hitherto unknown experiences and practices: on the contrary, clients and service providers will be very familiar with them. Rather, we are arguing that methadone maintenance treatment is materialising new ways of being that inflect the notion of biological citizenship in particular ways, especially in their dimensions of ethics and power. While liquid handcuffs, ‘chaotic’ users () and errant children are familiar enough figures to most people associated with treatment, the identities described below are also very common in treatment worlds, and reveal as much about what and how methadone materialises as do other, more stale and constrained subjects.

Throughout this post we will argue that there are at least four important elements to be added to the usual accounts of the ways in which new identities are materialised through methadone maintenance treatment. First, new selves are produced that occupy oblique positions relative to the positively and negatively remade selves described in many methadone texts. Second, these new selves may crop up in counterpoint or opposition to ‘official’ categories, become accommodated into the official accounts but also work to change them. This is Hacking’s looping feedback effect. Third, and similarly, the work of methadone maintenance treatment in creating new identities is not, or at least not always, a one-way process. New selves and identities also work to change the elements of methadone maintenance treatment, including its practical objects: service counters, waiting rooms and the drug methadone. Finally, when we are talking about the new identities materialised through methadone maintenance treatment and the ways in which they act to change the identity categories they occupy, we are not only talking about clients. The service providers who work in the field are also ‘made up’ and remade in this way.

This post is indebted to Foucault, Rose and Hacking, but we are not arguing that this single treatment is analogous to homosexuality, childhood, madness or the technologies that produced them. methadone maintenance treatment, as already noted, does not qualify as an instance of historical ontology; although it does enact important developments in biomedicine, governance and the constitution of the self under the conditions of neo-liberalism. We do not (yet) see much to be gained in pursuing an argument that the ‘methadone client’ is a historical development analogous to the ‘gay man’ or the ‘child abuse survivor’. But the identity of methadone client is important because it both relies on and disrupts the identity of the ‘drug addict’; and because it proposes important nuances to biological personhood and contemporary discourses around addiction, consumption, patienthood and care.