Todd Meyers, The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy, University of Washington Press, Seattle, 2013, 172 pages, $25 paperback, ISBN 9780295992419.

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Two initially confusing terms in the title of Todd Meyers’ book—elsewhere and afterlife—in fact provide an excellent starting point to understand the book’s contributions to the literature on addiction and drug treatment. While elsewhere reminds us that drug treatment has a geography, one that is never confined to the space of the clinic, afterlife points to the strange temporality of treatment and the problem of arbitrarily imposing a timeframe on the lived experience of addiction. For Meyers, the afterlife of treatment is not simply the time after the clinical trial has ended or the stint in rehab is over. Rather, the afterlife of therapy is something to be understood in the lived present: a present haunted by the ghosts of the past and the unknowable specter of the future. Afterlife and elsewhere are the excesses of drug treatment: they describe how the time after the trial has ended, the unquantifiable spaces beyond the clinic, and the variables that can’t be counted, are folded into the experience of treatment itself.

These excesses lie at the center of Meyers’ very fine book. It is a book about drug addiction and how the lived experience of addiction disrupts and overflows the categories that attempt to make sense of it. Based on three years of ethnographic fieldwork at a residential treatment center in Baltimore, the book follows 12 adolescents undergoing treatment for opiate abuse using buprenorphine, an opiate substitution medication. But while ethnography is central to The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy, this is also an attempt to do what Foucault called “philosophical anthropology” by making “visible precisely what is visible” (page 14). Seen this way, The Clinic and Elsewhere is arguably a book of philosophy more than it is a book of science, in the Foucauldian sense that it reevaluates the known rather than revealing the unknown.

There are two central questions in The Clinic and Elsewhere that correspond to the philosophical and ethnographic strands of Meyers’ project. The first is a philosophical consideration of clinical efficacy, where Meyers shifts focus from the question of whether buprenorphine is effective to ask how success and failure are defined in clinical trials. The second is the ethnographic and phenomenological question of how treatment is experienced and lived by those who undergo it. In formulating these questions, Meyers looks beyond Foucault to one of his teachers, the philosopher of science, Georges Canguilhem. Of central importance to Meyers is Canguilhem’s distinction between cure and healing. For Canguilhem, cure is fundamentally distinct from healing because it is premised upon the return to a prior state of health rather than a process of growth and development towards a new state. Furthermore, cure is the return to a norm and one that is defined by reference to a population while healing is a process particular to the subject. Following this distinction, we might guess that medical science would have far more to say about cure than it does about healing. But even cure proves difficult for the clinic, as Meyers demonstrates. The notion of cure is problematized by the “disease” of addiction, where the specter of relapse threatens the status of the subject as truly cured. As Meyers puts it, when it comes to drug abuse, “today always contains the possibility to unmake yesterday and tomorrow” (page 116). The afterlife of therapy—the pasts and futures that haunt treatment—makes it nearly impossible for the medical gaze to fix a time from which to assess the cured subject, for “the claim of success would require both a fixed window in time and a backward glance through this window … yet with the experience of addiction and recovery, so much is obscured beyond this frame” (ibid). Meyers’ work with Canguilhem’s ideas of cure and healing provide some of the most rewarding theoretical moments in the text, and he uses them to great effect in his examinations of clinical reasoning and therapeutics.

Beyond his philosophical contributions, Meyers’ attention to place will undoubtedly appeal to geographers, especially his argument that “therapy is held by space” (page 40). The space of the treatment center where Meyers conducted his research assumes a prominent position in the narrative, particularly in his discussion of the changing geographies of buprenorphine treatment compared to methadone (chapters two and three). Shifting therapy away from the methadone clinic to office-based settings has had profound geographical effects for opiate dependency treatment, Meyers argues. These effects parallel the changing profile of patients, as prescription opiate abusers increase relative to the older population of heroin users. Such changes do not benefit all patients, however, and Meyers’ description of Laura, one of the adolescents he follows, illustrates this, showing how her experiences receiving buprenorphine from a private physician fail to provide her with the therapeutic frame she requires. Laura eventually returns to the treatment center, despite her parents’ wishes to keep her from being swallowed by “the system”. Laura feels at home within the space of the treatment center and adheres to her treatment regime with far greater ease than when she finds herself elsewhere, living with her parents.

The ways that adolescents use the treatment center as a space away from the pressures and uncertainties of the world outside comes up again in chapter six, when we meet Keisha, whose own drug use appears to echo or respond to her mother’s. Against the received wisdom about children of addicted parents, however, Meyers argues that Keisha’s drug use is not simply a repetition of her mother’s addiction, nor is it a means of “escape” in and of itself. Rather, Keisha appears to use drugs both when the pressures of caring for her neglected siblings becomes overwhelming and as a strategy to force her mother to care for them once, she, Keisha, is institutionalized as a result.

The Clinic and Elsewhere is replete with such ethnographic vignettes, where Meyers offers sympathetic and richly textured readings of his subjects’ lives. Keisha and her mother’s story may be exemplary in this regard but it is far from unique. In chapter two, the author contrasts his own experience of being overwhelmed by the noise of the treatment center with the patient Devon’s remarks that the incessant noise provides a welcome respite from his interior life. This example showcases Meyers’ attention to the phenomenological aspects of residential drug treatment and of ethnographic fieldwork more broadly, as well as being a particularly subtle deployment of reflexivity. My favourite moment comes in chapter four, when Meyers introduces us to Cedric and Megan, a couple using buprenorphine to stabilize their heroin and oxycodone habits. Seen from the perspective of the clinic, the pair are “non-compliant” or questionably adherent to treatment because they continue to use illicit opiates alongside their buprenorphine regime. The nuanced perspective offered by Meyers’ ethnography, however, shows that the couple are committed to recovery on their own terms, maintaining a detailed log of the licit and illicit medications they take, and using it to chart their progress. Reading their efforts at self-care as a “simulacrum of clinical reasoning” (page 81), Meyers uses the couple to problematize the clinical categories of non-compliance and adherence to treatment. Alongside these important observations, Meyers also offers a reading of the couple’s relationship with a third figure, Wayne. Part drug dealer, part friend and confidant, would-be lover to both, Meyers’ reading of this group’s complex interpersonal dynamics, and the effects it has for their drug use, demonstrates a deep sensitivity for his subjects as well as a keen ability to read the ethnographic text. Readings such as these are perhaps the strongest feature of The Clinic and Elsewhere and make the book worthwhile reading for anyone interested in the literature on addiction and drug treatment, as well as medical anthropology and health geography more generally. All of Meyers’ ethnographic material is interesting, and at their best, his interpretations are truly beautiful.

Some of the finer theoretical points that Meyers attempts to make, however, seem to me less successful. In chapter five, for example, he argues that the patient is a “category of thought” (page 89). The patient is split between being the object of science and the subject of illness, between one who experiences and one who is observed. This formulation comes with a caveat where Meyers cautions that he is “not attempting to suggest some general theory of what (or who) a patient is or is not—such an exercise would be completely empty. Instead, I want to examine how the category of the patient is inhabited and lived…” (page 90). As the examples of Laura, Keisha, Cedric, and Megan show, Meyers is exceptionally good at examining the different ways these adolescents inhabit “patienthood”. That he nevertheless insists on the existence of a general category of patienthood runs counter to his text’s actual commitment to the lived and the particular, and comes across as confused. His claim that the patient is a category of thought, split between subject and object, between experience and the medical gaze, is thought-provoking but ultimately not satisfyingly elaborated. What does it mean that the patient is a category of thought—especially when Meyers subsequently dismisses a general theory of the patient as “completely empty”?

It is possible that these are simply disagreements over terminology, but in this argument and others (see also page 122, fn 43, regarding the relationship between the universal and the particular), Meyers draws very fine distinctions that come across as spurious or at least somewhat empty for their abstraction. One occasionally has the sense that these distinctions are almost unconscious attempts to wriggle out of thornier problems related to his commitment to the lived and particular over the abstract and universal. Even if this is not the case, I never understood exactly what was at stake in such distinctions—at least nowhere near as clearly as what was at stake in Meyers’ account of his subjects’ lives.

In the final analysis, however, these points are theoretical quibbles that hardly detract from Meyers’ exceptional work, which does a wonderful job of making “visible what is visible” about the lived realities of adolescent drug users, the emergent geographies of contemporary drug treatment, and the philosophical foundations of the clinic.