Princeton University Press, 2010.
323 pp., US$29.95 (paperback).
E. Summerson Carr’s Scripting Addiction is an ethnography of American talk therapy for drug users. It explores the myriad ways in which symptoms of addiction are constructed, identified, and managed in this setting. Carr’s rich and detailed prose takes her readers into the inner workings of Fresh Beginnings, an addictions treatment program for homeless women and part of a larger consortium of urban non-profits that seek to provide holistic service to families in crisis. Carr became involved with Fresh Beginnings during her training as a social worker; she began working at the agency as a student intern, gaining credit needed for her MSW degree. Over time, Carr expanded her training from applied social work to the theoretical social sciences, and her relationship with Fresh Beginnings shifted “from influencing program policy and practices as a fledgling social worker to describing and analyzing them as an ethnographer” (21). The end result of the three years she spent at Fresh Beginnings, of her numerous interviews clients and staff, her review of hundreds of program documents, and “countless hours of participant observation” (21), is a thorough (and thoroughly convincing) analysis of the linguistic politics of drug treatment. Through textual analysis and ethnographic vignettes, Carr seeks to convince the reader of her premise that addiction therapy is “focused on reconfiguring clients’ relationship with language rather than simply, or even primarily, reconfiguring their relationship to drugs” (3).
Scripting Addiction represents a new kind of drug use ethnography—one that has been steadily emerging in the last few years, replacing the theoretical frames that have long been typical of drug use ethnography (structural violence (Spradley 1968), biopower (Bourgois 2000), governmentality (Campbell and Shaw 2008), labeling (Becker 1963), etc.) with new and innovative approaches that draw heavily from the literature on science studies, narrative analysis, social work theory, and semiotics. Of particular note in this new genre is Maria Yellow Horse Brave Heart’s (2003) development of Historical Trauma theory. Brave Heart uses this concept to illuminate historical and intra-familial patterns that cause and perpetuate high rates of alcoholism among Lakota families in North America. Equally representative is the work of Angela Garcia (2010), who has taken up the concept of melancholia (originally developed by Freud) to explain frequent and occasionally violent recidivism among drug treatment patients in rural New Mexico. Following suit, Carr’s Scripting Addiction offers a compelling description of the “semiotic work” (5) undertaken by the staff of an American drug treatment center in order to impart specific ideologies of relatedness, truthful inner reference, and self-presentation among patients. In her own words, Carr asserts that her ethnography “contributes uniquely to this literature by approaching addiction treatment as a site where ideologies of language are refined and reproduced, processing people along the way” (233).
At Fresh Beginnings, the identification of addiction is seen by counselors and staff as more of an intuitive act than a standardized, diagnostic one. Denial, a fluid and flexible psychological concept, is seen as the primary symptom of addiction (as discussed in Chapters 3 and 4). When identified in a client, denial serves as a definitive symptom in and of itself, as well as ample evidence that other symptoms of substance dependence are present in an individual as well. As a result, the psychological terrain of a Fresh Beginnings’ client is imagined in a specific, topographical way (illustrated on pp.93). Clients’ true, inner states are believed to lay deep within them, obscured, and rendered unreachable underneath thick, impenetrable layers of anger and denial. For this reason, the professional intuition and clinical expertise of Fresh Beginnings’ treatment counselors is needed to identify truth, to recognize denial, and to give a valid name to the inner mental and emotional states of their clients. In contrast to the conventional wisdom that ‘addicts always lie,’ Fresh Beginnings’ philosophy claims that addicts simply aren’t capable of speaking the truth, since addicts’ access to their own inner states is blocked by their pathological denial.
The therapeutic approach adopted by Fresh Beginnings’ staff also reflects clinical literature from the 1990s (current at the time or research) that finds a high correlation between childhood sexual abuse and adult substance dependence among women. As one client explained, “You got to be abused there, or they start thinking’ there be somethin’ wrong with you” (115). Thus, the etiology of addiction in Fresh Beginnings’ entirely female client population (discussed in Chapter 3) is understood in this way: through the oppression of the shame and anger resulting from traumatic childhood experiences (i.e., sexual abuse), addicts are believed to have repressed their feelings and memories too much, to have over-shot the mark with their self-medication, irreparably distancing themselves from the truth of all personal experiences and emotions. Recovery, then, must consist of ‘excavating’ emotional truths from beneath the calloused layers of shame, anger, and denial that characterize the addicted psyche.
In addition to providing readers with a captivating narrative, Scripting Addiction offers numerous theoretical contributions to the fields of linguistics, cultural anthropology, and social work. Perhaps Carr’s most significant contribution is a more detailed understanding of the American conception of addiction. Carr lucidly reveals that the major concerns of American addictions treatment revolve around the politics of referential speech and the policing of speech practices among recovering clients. She suggests that the goal of the treatment program is to make the clients into sober persons by coaching them into patterns of sober speech (see Chapters 1, 2, and 4). Carr skillfully leads the reader to wonder whether the social problems posed by addiction are not of personal behavior or volition on the part of the addict, but rather of the addict’s modes of social interaction and self-presentation.
In this exploration of the ‘nature’ of addiction, Carr’s methodology surpasses the cognitive (Agar 1973, Spradley 1968) and social constructionist (Becker 1963, Dai 1937, Lindesmith 1968) approaches to drug use seen in previous decades. Her analysis reveals that clinical narratives of substance abuse and substance dependence are built more firmly around culture-bound notions of proper self-representation and referential speech than they are around criminality, disease, or maladaptive behavior. It reveals that the addicts’ subjectivity is dependent upon dominant ideologies of personhood rather than social structure, labeling, or subculture. In Carr’s view, addicts are troubling to society not because they are ‘ill’ or even because they are deemed to be ‘deviant’ in a criminal way. Rather, they are troubling because they exist in a realm that is epistemologically troubled, a realm that is “outside of truth” as truth is defined by American cultural logic. Addicts challenge the fundamental premises of the dominant American ontology of personhood—that each person’s true inner self can be cleanly and directly referenced in an unmediated way (224)—because “[addicts] do not recognize themselves” (86, original emphasis).
Second, Carr’s research illuminates a challenge faced by treatment counselors at Fresh Beginnings that is also faced by ethnographers: namely, the impossibility of determining whether a speaker who is deploying institutionalized frames and narratives is following or ‘flipping’ the scripts at their disposal (see Chapters 5 and 6). For her purposes, Carr defines ‘flipping the script’ as “a kind of procedural knowledge derived from careful and continuous attunement to one’s immediate environment” (191). In other words, clients perform acts of inner reference and tell treatment staff what they think they want to hear. As one client observed, “I’m a prostitute. It’s what I do…I tell people what they want to hear” (190). For example, when female clients engage with feminist critiques of Alcoholic Anonymous in order to voice their discontent with mandatory meetings (as discussed in Chapter 6), there is an “evidentiary crisis” (195) at hand for the staff. Are the clients following this script or flipping it? What is the difference, and how could it be detected?
This ‘evidentiary crisis’ faced by treatment counselors also raises important methodological questions for Carr as a anthropologist – namely what degree of access does she have as an ethnographer to the inner thoughts and realities of her informants. Carr made this connection after an interviewee, Shauna, confessed to having ‘flipped a script’ on her during an ethnographic (i.e., non therapeutic) interview. This incident is presented in the introduction as follows:
Seeking to start where we had left off, I reminded [Shauna] of a touching anecdote she had told me at the end of her second interview about a recovering alcoholic “John”-turned-lover who had “transformed” her life by lovingly encouraging her to seek treatment. Her response to my query was unnerving but highly instructive:
I [Carr]: So that’s where we left off [in our last interview].
N [informant]: (long pause…laughter) Oh my. (laughter).
N: I told you that (laughter).
I: Yeah (giggle)…don’t you remember?
N: You knew that didn’t happen, right? (laughter). Please tell me.
N: Oh, poor ol’ Summerson (sigh). Girl, don’t you know I flipped a script on you?!” (18).
Carr astutely observes that the script flipping observed here raises an issue that “has long concerned anthropologists: the limits of informants’ awareness of native cultural forms and how that awareness is accessed” (195). Carr elaborates, “When ethnographers do not separate out what informants say about their language from what those informants are aware of, we confine ourselves, methodologically, within the boundaries of a language ideology that takes words as signs of what speakers “really” know and think” (196). Indeed, the potential conundrum that this observation poses for ethnographers is the same as that faced by the Fresh Beginnings staff, because script flipping in each context is the same political act. Carr does not offer a happy solution to this quandary, but rather presents the problems itself as inherent to any activity that seeks to identify the personal referents of others’ speech. Her interaction with Shauna is, more than anything, a cautionary tale, warning ethnographers and social workers alike against conflating informants’ metalinguistic awareness and their ability to describe metalinguistic features of their speech.
Finally, Carr’s analysis reveals the ways in which clients, positioned as illegitimate speakers in an institution that seeks to govern and discipline their speech, can claim agency by acting within the roles and identities proscribed to them. In Chapter 5, Carr draws upon the theories of Judith Butler and Louis Althusser to elaborate a linguistic strategy that she calls anticipatory interpellation, and act “in which some clients…not only responded ‘like addicts’ across institutional settings, but also called on powerful others to address them as such” (153). Carr observed metalinguistically savvy clients at Fresh Beginnings engaging the highly limited speech patterns institutionally imposed upon them in order to “speak effectively from these designated locales, in politically efficacious ways” (154). By successfully performing the addicted personhood they were supposed to occupy, some clients were able to mobilize institutional authority as a resource for gaining social, symbolic, or material benefits, rather than simply being hindered by it.
To this end, Carr suggests that her analysis offers “a viable alternative to theories of power that suggest a simple equation between ideology and resistance—whether cast in the terms of zero-sum or in Foucault’s popular formation (i.e., where there is power, there is resistance)” (226). She concludes that script flipping is a deliberate, political act that requires critical awareness of local metalinguistic ideologies as well as a deft, capable, and well-contextualized performance. Script flipping, then, incontrovertibly demonstrates that addicts in treatment are able to deploy complex, adaptive strategies from within in an environment that is designed to stifle their so-called maladaptive behaviors.
There is a strong body literature at the intersection of drug use, public health, and critical medical anthropology that theorizes drug treatment and harm reduction programs in terms of Foucaultian theories of power like biopower and governmentality (c.f. Bourgois 2000, Bourgois and Schoenberg 2009, Campbell and Shaw 2008, Lupton 1995). Philippe Bourgois, even while overtly engaging with these theories in his analysis of American methadone programs, has noted that “Foucault’s theoretical understanding of the way power permeates truth, knowledge and even oppositionality, [can lead] to paralysis” (2000: 188). Carr’s accomplishment here is the articulation of an exit from this theoretical paralysis, a way to perceive and talk about social actors as agents, even from within a profoundly oppressive system.
Overall, Carr’s prose is clear, fluid, and easy to read—something of a necessity given the depth and complexity of the anthropological and linguistic theory that she engages. Although it is well organized, her text is complicated by the fact that she has so many things to say about her chosen subject. In her conclusion, Carr details no less than six major theoretical arguments presented in her text, and I dare say that this list barely covers all of take-away points that Scripting Addiction has to offer. The inexperienced reader might find this to be a significant obstacle, which is why I am hesitant to recommend this book for undergraduate courses. However, Carr’s skill in ethnographic interviewing and in textual analysis is readily apparent, and selected vignettes from this book could be extremely enlightening for younger students. For example, Chapter 4 (“Addicted Indexes”) details a particularly disturbing scene in which a female client refers to a romantic acquaintance with the gender-neutral pronoun ‘they.’ Duty bound to enforce unmediated referential speech in her clients, a treatment counselor forcefully ‘outs’ this client as homosexual in a group therapy session by attacking the ‘evasiveness’ of her pronoun choice. Moments in Carr’s text such as this one reveal the effects of power, subjectivity, and language politics in their barest form and could be quite instructive for students of any social discipline—from linguistic anthropology to sociology to social work.
Advanced scholars in the fields of medical anthropology, social work, or public health policy will find Carr’s book both terribly familiar and refreshingly innovative. As someone acquainted with the treatment setting that she analyzes, I found her text both exciting and deeply satisfying for the ways in which it resonated with my own experiences. I believe that this is a reaction that many others will share. At the same time, Carr’s methodological rigor has produced new ways of understanding problems that have been familiar to critical studies to addiction and public health for quite some time. As such, this book deserves to be a significant figure in both theoretical and practical conversations about the ‘management’ of addicts, addiction, and other so-called ‘unreasonable’ elements of society for some time to come.
Agar, Michael. 1973. Ripping and Running: A Formal Ethnography of Urban Heroin Addicts. New York: Academic Press.
Becker, Howard. 1963. Outsiders: Studies in the Sociology of Deviance. New York: The Free Press.
Bourgois, Philippe. 2000. “Disciplining Addictions” Culture, Medicine and Psychiatry 24: 165–195.
Bourgois, Philippe and Jeffrey Schonberg. 2009. Righteous Dopefiend. Berkeley: University of California Press.
Brave Heart, Maria Yellow Horse. 2003. “The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: a Lakota Illustration.” Journal of Psychoactive Drugs 35(1): 7-13.
Campbell, Nancy D. and Susan J Shaw. 2008. “Incitements to Discourse: Illicit Drugs, Harm Reduction, and the Production of Ethnographic Subjects” Cultural Anthropology 23(4): 688-717.
Dai, Bingham. 1937. Opium Addiction in Chicago. Montclair, NJ: Patterson Smith.
Garcia, Angela. 2010. The Pastoral Clinic: Addiction and Dispossession along the Rio Grande. Berkeley: University of California Press.
Lindesmith, Alfred R. 1968. Addiction and Opiates. Chicago: Aldine.
Lupton, Deborah. 1995. The Imperative of Health: Public Health and the Regulated Body. London: Sage.
Spradley, James. 1968. You Owe Yourself A Drunk. Prospect Heights, IL: Waveland Press.
Jennifer Carroll is a medical anthropologist who researches gendered identity and drug addiction in the US and in Ukraine. She is currently working towards her Ph.D. in Socio-cultural Anthropology at the University of Washington. She also holds an M.A. in Sociology from Central European University and a B.A. in Anthropology from Reed College. Her early work focused on identity and subjectivity among drug users in Ukrainian harm reduction programs. Currently, through her dissertation research, she seeks illuminate how and why opiate users in Ukraine decide to seek out substitution therapy and adhere to treatment protocols from day to day.