Serenity: Violence, Inequality, and Recovery on the Edge of Mexico City

The cultural turn in understanding 'addiction'

In this essay we want to foreground a question: what happens to 'addiction' when we take seriously cultural scripts informing its trajectories? Can this bring us to unthink addiction as problematic notion and move it onto new paradigms that fit better the now acknowledged fluidity and pluralistic episteme of 'addiction' and more broadly of chronic life conditions? Indeed, 'addiction' has become a pivotal concept in the contemporary world. A powerful diagnostic framework in interpreting human behaviour, for some 'addiction' has become the 'new normal' with chronic relations with different things such as food, sex, gambling, and mind-altering substances touching upon the lifestyle of a majority of individuals, making everyone 'addicts in practice'. Perhaps this has something to do with the constituent force that 'habit' - as in 'addiction' - has in defining our present and future. Though 'addiction' goes beyond the question of mind-altering drugs, the politics of 'addiction' is intimately tied to substances such as opioids and opiates, cocaine, cannabis, and psychedelics that have been the object of durable systemic political control and security repression. Contextually the line between licit/illicit substances is softening and blurring, the 'dual' purpose that drugs serve is now recognised in scientific and popular analysis moving the question of 'addiction' beyond the medicine/drug dichotomy. Yet, culture is generally absent in understanding 'addiction.' When it is referred to, this happens in diminutive terms limited to Anglo-American modern culture. Culture matters and it matters with different weights and measures as it moves across the world. There are cultural environments of health informed by practices and epistemologies of well-being that have evolved in lines opposites from or only intersecting with the Anglo-American, and generally Western, world. Exploring these spaces and cultural scripts enables our scholarship on drugs and 'addiction' to move the barycentre of discussion towards novel considerations around the historical trajectories and potential futures of our diagnostic terms and policy interventions.

Living the Process: Examining the Continuum of Coercion and Care in Tijuana's Community-Based Rehabilitation Centers

In Mexico, community-based, non-biomedical treatment models for substance use are legally recognized in national drug policy, monitored by state-level Departments of Health, and in some cases publicly funded. Academic research on centers that utilize these forms of treatment have focused primarily on documenting their rapid spread and describing their institutional practices, particularly human rights abuses and lack of established biomedical efficacy. In Tijuana, these community-based therapeutic models are shaped by conceptions of health and illness from the local cultural context of the United States-Mexico border zone in ways that do not cleanly match western, biomedical notions of the illness "addiction." In this article, I examine treatment ethics by exploring the contextually understood need for coerced treatment (i.e., why centers are locked) along with experiences of compulsion in a women's 12 Step center. These discussions highlight the contested therapeutic value of coercion from multiple perspectives. Utilizing engaged listening around local care practices marks a path for global mental health researchers to understand and sit with difference in order to communicate across opposing viewpoints in the service of mental health equity and best care practices.

A scoping review of how exposure to urban violence impacts youth access to sexual, reproductive and trauma health care in LMICs

Violence in the community can impact access to health care. This scoping review examines the impact of urban violence upon youth (aged 15-24) access to sexual and reproductive health and trauma care in Low and Middle Income Countries (LMICs). We searched key electronic health and other databases for primary peer-reviewed studies from 2010 through June 2020. Thirty five of 6712 studies extracted met criteria for inclusion. They were diverse in terms of study objective and design but clear themes emerged. First, youth experience the environment and interpersonal relationships to be violent which impacts their access to health care. Second, sexual assault care is often inadequate, and stigma and abuse are sometimes reported in treatment settings. Third is the low rate of health seeking among youth living in a violent environment. Fourth is the paucity of literature focusing on interventions to address these issues. The scoping review suggests urban violence is a structural and systemic issue that, particularly in low-income areas in LMICs, contributes to framing the conditions for accessing health care. There is a gap in evidence about interventions that will support youth to access good quality health care in complex scenarios where violence is endemic.

A Second Chance: Reenactment and Recovery Narratives in a Peruvian Drug Rehabilitation Center

The following article discusses a collaborative, reenactment film made with the residents of a drug rehabilitation center in Iquitos, Peru. In so doing, it raises questions about narratives of recovery from addiction, and the tensions that emerge between these narratives and the often-ambivalent feelings of the people who tell them. Practices of filmmaking and reenactment generate a collaborative theorization of lived experience-in this case, the multifaceted natures of both addiction and recovery. At the same time, these practices are also attentive to the embodied memories and complex feelings of the film's actors. Further engagement with the filmic materials demonstrates how the film became an active exploration of the ongoing nature of recovery, complicating the therapeutic trajectories of a group of actors struggling to reconcile ambivalent feelings as they attempt to craft new narratives of self.

'Acute-on-chronic': Emergency Affect and the One-way Staircase of Pharmaceutical Escalation

The opioid epidemic in the United States is often portrayed as leading to a "pendulum swing" from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed "emergency affect," a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this "emergency affect" can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.

What Escapes Persuasion: Why Intellectual Disability Troubles 'Dependence' in Liberal Societies

What expectations about the mind do people with intellectual disabilities depart from? A dominant argument maintains that their mental dependence troubles liberal relations premised upon a myth of autonomy. By analyzing the centrality of persuasion in a home for adults with intellectual disabilities in the UK, I ask instead about the psychological assumptions made by relationships of care. Persuasion aims to cultivate, not their independence from care but rather, a recognition of their dependence upon it. Persuasive care's repeated failure suggests an alternative answer to the question: people with intellectual disabilities are too independent-minded for this form of dependence.

Necropolitics in the "Compassionate" City: Care/Brutality in San Francisco

In San Francisco in the United States, the urban precariat is governed simultaneously by two logics of intervention that are highly contradictory: compassion and brutality. In this article, I explore the contours of violence embedded in humanitarian governance for unstably housed/homeless women who use drugs as they navigate care systems for their health and well-being. I use Mbembe's concept of necropolitics to examine how women embody an anticipation of death, at the same time as they manage their risk for actual death in engagements with care in a city paradoxically known for its progressive, compassionate principles of intervention for those who are most marginalized.

From Treatment to Containment to Enterprise: An Ethno-history of Therapeutic Communities in Puerto Rico, 1961-1993

Unpaid work is now a central therapy in Puerto Rican therapeutic communities, where substance users reside and seek to rehabilitate each other, often for years at a time. Once a leading treatment for addiction in mainland United States, therapeutic communities were scaled back in the 1970s after they lost federal endorsement. They continue to flourish in Puerto Rico for reasons that have less to do with their curative powers than with their malleability as multi-purpose social enterprises and their historical co-option by state, market and family actors who have deployed them for a variety of purposes. Their endurance from the 1960s to the neoliberal present obliges us to recognize their capacities as what Mizruchi calls abeyance mechanisms whereby 'surplus' populations, otherwise excluded from labor and home, are absorbed into substitute livelihoods. Having initially emerged as a low-cost treatment, in a context of mass unemployment and prison-overcrowding they now thrive as institutions of containment and informal enterprise.

Beyond China's drug century: Yunnan's first therapeutic community and narratives of drug treatment and mental health care

China is experiencing rapid cultural change and new forms of sociability that are accompanied by social problems and novel humanitarian interventions that have been formulated to address those problems. The pressure related to the rapid transformation of the countryside into mid-level cities has led to recreational drug-use as a means of escape. These illegal drugs have greased the wheels of what I call an affective biopolitics that has influenced Chinese citizens. Carlos Rojas argues that development in China results from the effects of discrete protocols, or practices that stem from tensions between capital and labor, governmentality and biopolitics, and nationalism and globalization. To tease out the particulars of Rojas' protocols and practices, in this article, I first review two historical periods: 1) the rise and fall of opium consumption in the early 19th century, and 2) the 21st-century psychology boom. I use these two literature reviews to set the stage to discuss my ethnographic study of Sunlight, China's first residential therapeutic community for drug users in Yunnan Province. Sunlight's residents and founders provide a unique window into local everyday drug use at a particular time in China's economic boom, from 2007 through 2015. We know much about China's opium century but very little about the contemporary context, new consumers who partake in pleasure-consuming drugs, or the reformers who address these 21st-century public health issues.

"Somebody Is Gonna Be Hurt": Involuntary Drug Treatment in Mexico

Involuntary drug treatment (IDT) is ineffective in decreasing drug use, yet it is a common practice. In Mexico, there are not enough professional residential drug treatment programs, and both voluntary and involuntary drug treatment is often provided by non-evidence based, non-professional programs. We studied the experiences of people who inject drugs (PWID) in Tijuana who were taken involuntarily to drug centers under the auspices of a federally funded police operation. We provide insight into how the health, wellbeing, human rights, dignity, and security of PWID ought to be at the center of international drug policies included in universal health care systems.

Care Wounds: Precarious Vulnerability and the Potential of Exposure

What does it mean to offer care when the act of caring is wounding to its giver? For peer specialists-individuals with lived experience as patients in the psychiatric system-this question shapes how they use their own histories to provide support for individuals experiencing psychiatric crisis. Peer support is unique in the way it draws on empathetic resonance and depends on carefully deployed vulnerability; where one connects with others through the recognition of shared experience and mutual hurt. For peers, care works when this guidance, reassurance, and "being with"-all of which draw upon their own stories of traumatic history and variegated suffering-mitigate the present crisis being experienced by another. Drawing on twenty-eight months of fieldwork with a peer-staffed crisis respite center in the eastern United States, I argue that the peer specialist becomes the embodiment of a novel intersection of intimacy and compensation; one that poses vulnerability not as a consequence, casualty, or risk factor in the commodification of care, but as its principle vector of resonance and the assumption on which it is based. For peers, care that works-in that it creates a mutual resonance for the recipient-becomes simultaneously care that wounds its giver.

Commentary on Rafful et al. (2018): Unpacking involuntary interventions for people who use drugs

Involuntary interventions for substance use disorders are less effective and potentially more harmful than voluntary treatment, and involuntary centers often serve as venues for abuse. Scaling up voluntary, evidence-based, low-barrier treatment options might invalidate the perceived necessity of involuntary interventions, and could go a long way toward reducing overdose risk.

Luisa's Ghosts: Haunted Legality and Collective Expressions of Pain

Feminist health care providers have debated the efficacy of the decriminalization of abortion in Mexico City. Luisa, a counselor in a private clinic, suggested that while the law has expanded the visibility of, and access to safe abortion, it has also called forth "other ghosts." In this article, I take Luisa's critical perspective as a starting point for examining ongoing criminalization and moral stigma as forms of haunting that arise in the wake of the Mexico City abortion policy. Drawing on ethnographic research, I explore how Luisa's ghosts materialize in the embodied- affective relations between patients in new legal clinics. Women who attend public clinics negotiate moral stigma along with religious and familial pressures in the ways they suffer, as well as normalize abortion as a painful experience. Rather than approach pain as purely a sign of victimization, I suggest that its expression constitutes an effervescent collectivity between women in the clinic, making explicit, while at the same time dissipating, an intractable moral-affective knot that might otherwise be ignored.

Lawful Sinners: Reproductive Governance and Moral Agency Around Abortion in Mexico

The Catholic Hierarchy unequivocally bans abortion, defining it as a mortal sin. In Mexico City, where the Catholic Church wields considerable political and popular power, abortion was recently decriminalized in a historic vote. Of the roughly 170,000 abortions that have been carried out in Mexico City's new public sector abortion program to date, more than 60% were among self-reported Catholic women. Drawing on eighteen months of fieldwork, including interviews with 34 Catholic patients, this article examines how Catholic women in Mexico City grapple with abortion decisions that contravene Church teachings in the context of recent abortion reform. Catholic women consistently leveraged the local cultural, economic, and legal context to morally justify their abortion decisions against church condemnation. I argue that Catholic women seeking abortion resist religious injunctions on their reproductive behavior by articulating and asserting their own moral agency grounded in the contextual dimensions of their lives. My analysis informs conversations in medical anthropology on moral decision-making around reproduction and on local dynamics of resistance to reproductive governance. Moreover, my findings speak to the deficiencies of a feminist vision focused narrowly on fertility limitation, versus an expanded framework of reproductive justice that considers as well the need for conditions of income equality and structural supports to facilitate reproduction and parenting among women who desire to keep their pregnancies.

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla's Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations' efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a "global psychiatry" informed by global policy will fail because it cannot exist in a uniform way-interpersonal interaction and personal experience matters.

Perceived Treatment Need and Latent Transitions in Heroin and Methamphetamine Polydrug Use among People who Inject Drugs in Tijuana, Mexico

People who inject drugs (PWID) in Tijuana, Mexico, use heroin and/or methamphetamine. While polydrug use is associated with HIV risk behavior, less is known about the stability of polydrug use patterns over time and how polydrug use is related to perceived treatment need. Within a cohort of PWID in Tijuana (N = 735) we sought to (1) characterize subgroups of polydrug and polyroute use from baseline to six months; (2) determine the probabilities of transitioning between subgroups; and (3) examine whether self-reported need for help for drug use modified these transition probabilities. Latent transition analysis (LTA) identified four latent statuses: heroin-only injection (38% at both baseline and follow-up); co-injection of heroin with methamphetamine (3% baseline, 15% follow-up); injection of heroin and methamphetamine (37% baseline, 32% follow-up); and polydrug and polyroute users who injected heroin and both smoked and injected methamphetamine (22% baseline, 14% follow-up). Heroin-only injectors had the highest probability of remaining in the same latent status at follow-up. The majority reported great or urgent need for treatment (51%) and these PWID had greater odds of transitioning to a higher-risk status at follow-up, emphasizing the need for evidence-based drug treatment options for PWID.

Hope Amidst Horror: Documenting the Effects of the "War On Drugs" Among Female Sex Workers and Their Intimate Partners in Tijuana, Mexico

Sensationalistic media coverage has fueled stereotypes of the Mexican border city of Tijuana as a violent battleground of the global drug war. While the drug war shapes health and social harms in profoundly public ways, less visible are the experiences and practices of hope that forge communities of care and represent more private responses to this crisis. In this article, we draw on ethnographic fieldwork and photo elicitation with female sex workers who inject drugs and their intimate, non-commercial partners in Tijuana to examine the personal effects of the drug war. Drawing on a critical phenomenology framework, which links political economy with phenomenological concern for subjective experience, we explore the ways in which couples try to find hope amidst the horrors of the drug war. Critical visual scholarship may provide a powerful alternative to dominant media depictions of violence, and ultimately clarify why this drug war must end.

Sociopolitical contexts for addiction recovery: Anexos in U.S. Latino communities

BACKGROUND

Anexos are community-based recovery houses that were created in Mexico to serve people struggling with addiction to alcohol and other drugs. Brought to the U.S. by Mexican migrants, anexos provide residential care to primarily male Latino migrants and immigrants who are unable or unwilling to access formal treatment. While some Mexican anexos have come under fire for coercion, confrontational treatment methods, and corporal punishment, little is known about treatment practices in U.S. anexos.

METHODS

We conducted a two-year ethnographic study of three anexos in urban Northern California. The study included over 150h of participant observation and semi-structured interviews with 42 residents, 3 directors, 2 assistant directors, and 3 former directors (N=50). Qualitative data were analyzed thematically using ATLAS.ti software.

RESULTS

The anexos in our study differed in important ways from Mexican anexos described in the scientific literature. First, we found no evidence of corporal punishment or coercive internment. Second, the anexos were open, allowing residents to leave the premises for work and other approved activities. Third, the anexos were self-supported through residents' financial contributions. Fourth, collective decision-making processes observed in the California anexos more closely resembled sober living houses than their authoritarian counterparts in Mexico.

CONCLUSION

Anexos may operate differently in the U.S. versus Mexico due to variations in sociopolitical context. This exploratory study suggests that anexos are addressing unmet need for addiction treatment in U.S. Latino immigrant and migrant communities. As a community-created, self-sustained, culturally appropriate recovery resource, anexos provide important insights into Latino migrants' and immigrants' experiences with substance abuse, help-seeking trajectories, and treatment needs.

Distribution and Neighborhood Correlates of Sober Living House Locations in Los Angeles

Sober living houses (SLHs) are alcohol and drug-free living environments for individuals in recovery. The goal of this study was to map the distribution of SLHs in Los Angeles (LA) County, California (N = 260) and examine neighborhood correlates of SLH density. Locations of SLHs were geocoded and linked to tract-level Census data as well as to publicly available information on alcohol outlets and recovery resources. Neighborhoods with SLHs differed from neighborhoods without them on measures of socioeconomic disadvantage and accessibility of recovery resources. In multivariate, spatially lagged hurdle models stratified by monthly fees charged (less than $1400/month vs. $1400/month or greater), minority composition, and accessibility of treatment were associated with the presence of affordable SLHs. Accessibility of treatment was also associated with the number of affordable SLHs in those neighborhoods. Higher median housing value and accessibility of treatment were associated with whether a neighborhood had high-cost SLHs, and lower population density was associated with the number of high-cost SLHs in those neighborhoods. Neighborhood factors are associated with the availability of SLHs, and research is needed to better understand how these factors affect resident outcomes, as well as how SLHs may affect neighborhoods over time.

Violence, addiction, recovery: An anthropological study of Mexico's anexos

Informal, coercive residential centers for the treatment of addiction are widespread and growing throughout Latin America. In Mexico these centers are called "anexos" and they are run and utilized by low-income individuals and families with problems related to drugs and alcohol. This article draws on findings from a 3-year anthropological study of anexos in Mexico City. Participant observation and in-depth interviews were used to describe and analyze anexos, their therapeutic practices, and residents' own accounts of addiction and recovery. Our findings indicate that poverty, addiction, and drug-related violence have fueled the proliferation of anexos They also suggest that anexos offer valuable health, social, and practical support, but risk exacerbating the suffering of residents through coercive rehabilitation techniques. Emphasizing this tension, this article considers the complex relationship between coercion and care, and poses fundamental questions about what drug recovery consists of in settings of poverty and violence.

The effectiveness of compulsory drug treatment: A systematic review

BACKGROUND

Despite widespread implementation of compulsory treatment modalities for drug dependence, there has been no systematic evaluation of the scientific evidence on the effectiveness of compulsory drug treatment.

METHODS

We conducted a systematic review of studies assessing the outcomes of compulsory treatment. We conducted a search in duplicate of all relevant peer-reviewed scientific literature evaluating compulsory treatment modalities. The following academic databases were searched: PubMed, PAIS International, Proquest, PsycINFO, Web of Science, Soc Abstracts, JSTOR, EBSCO/Academic Search Complete, REDALYC, SciELO Brazil. We also searched the Internet, and article reference lists, from database inception to July 15th, 2015. Eligibility criteria are as follows: peer-reviewed scientific studies presenting original data. Primary outcome of interest was post-treatment drug use. Secondary outcome of interest was post-treatment criminal recidivism.

RESULTS

Of an initial 430 potential studies identified, nine quantitative studies met the inclusion criteria. Studies evaluated compulsory treatment options including drug detention facilities, short (i.e., 21-day) and long-term (i.e., 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment. Three studies (33%) reported no significant impacts of compulsory treatment compared with control interventions. Two studies (22%) found equivocal results but did not compare against a control condition. Two studies (22%) observed negative impacts of compulsory treatment on criminal recidivism. Two studies (22%) observed positive impacts of compulsory inpatient treatment on criminal recidivism and drug use.

CONCLUSION

There is limited scientific literature evaluating compulsory drug treatment. Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.

Risk of violence in drug rehabilitation centers: perceptions of people who inject drugs in Tijuana, Mexico

Background

In 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at “Peer Support” (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico.

Methods

Secondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement “going to rehabilitation puts me at risk of violence”. Logistic regression was used to examine factors associated with perceived risk of violence.

Results

Of 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level.

Conclusion

The perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs’ concerns about violence.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0044-z) contains supplementary material, which is available to authorized users.