Spaces of abeyance, care and survival: The addiction treatment system as a site of ‘regulatory richness’

Political Geography 28 (2009) 463–472

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Political Geography journal homepage: www.elsevier.com/locate/polgeo

Spaces of abeyance, care and survival: The addiction treatment system as a site of ‘regulatory richness’ Geoffrey DeVerteuil a, *, Robert Wilton b a b

University of Southampton, School of Geography, Highfield Campus, Southampton SO17 1BJ, United Kingdom School of Geography and Earth Sciences, McMaster University, Hamilton (Ontario), Canada L8S 4M1

a b s t r a c t Keywords: Welfare state Addiction treatment system Abeyance Care Survival

This paper uses the changing landscape of the addiction treatment system as a way to understand broader trends in welfare state restructuring. Based on a case study of six detoxes in Winnipeg, Hamilton and Toronto (Canada), we seek to understand the degree to which the detox constitutes a space of care that reflects therapeutic aims of facility operators, a space of abeyance, control and containment for larger society, and a space of sustenance for individual clients. Further, we investigate how the shifting relationships between these roles provide insight into broader trends in the structuring and restructuring of the welfare state. Our empirical findings point to a multiple and reworked configuration within detox programs, while conceptually, our tripartite understanding of spaces of treatment serves to caution against totalizing accounts of current welfare state restructuring. Ó 2009 Elsevier Ltd. All rights reserved.

Introduction The geography of intoxicants is a small, nascent subfield at the intersection of health and social geography. By the geographies of intoxicants, we mean the multiple ways in which the production, consumption/prevalence, regulation and treatment of intoxicants are both shaped by and reflected in the structure of the social environment across multiple scales. Geographically-inclined work on intoxicants has primarily focused on consumption and regulation within public spaces, as well as public health concerns over substance abuse (e.g., Jayne, Holloway, & Valentine, 2006; Smith, 1988; Smith & Hanham, 1982). Far less work has focused on the potentially revealing nature of the addiction treatment system as a component of the broader welfare state. In one sense, the system may act as a platform for operators’ therapeutic aims; for larger society, the system may act to contain and control people deemed disruptive and unproductive; and for individuals in treatment, the system may act as a critical node of survival. Aligning with these claims, several authors have argued that societies’ responses to consumption and addiction constitute a fertile ground for research because efforts to regulate and respond to the consumption of intoxicants involve complex interactions between multiple forms of governance that are embedded within a residual, non-universalistic and conflicted and contingent treatment system (e.g.,

* Corresponding author. Tel.: þ44 23 8059 9622; fax: þ44 23 8059 3295. E-mail address: [email protected] (G. DeVerteuil). 0962-6298/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.polgeo.2009.11.002

Fairbanks, 2009; Valverde, 1998). Fairbanks (2009, p. 25), for example, has argued that sites within the addiction treatment system come to spatially and discursively embody ‘‘the political strategies and regulatory strategies of the postindustrial city’’. In this paper, we ask two questions of the addiction treatment system. First, how does the addiction treatment system constitute a space of care that reflect therapeutic aims of facility operators, a space of abeyance, control and containment for larger society, and a space of sustenance for individual clients? And second, given that the addiction treatment system is a site of ‘regulatory richness’ (Valverde, 1998), how do the shifting relationships between these roles of abeyance, care and survival provide insight into broader trends in the structuring and restructuring of the welfare state? In an immediate sense, our analysis helps to shed light on a poorly understood yet critically important sector of health and social welfare. More broadly, our examination contributes to (and bridges) a range of concerns within urban, health, political and social geography. Conceptually, our research serves to shed light on how the practices of agencies within the addiction treatment system and the everyday actions of individual clients both reflect, embody and resist broader trends in welfare restructuring, cautioning against totalizing accounts of current welfare state restructuring (see also Fairbanks, 2009). We also contribute to a more relational approach to the geographies of poverty, in which clients and facility operators are struggling to adapt to new realities. Terminology surrounding problem use of intoxicants is complex. In this paper, we use ‘‘addiction’’ to talk about situations

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in which people are perceived to have lost control over use of drugs and/or alcohol. Although psychiatry has abandoned ‘‘addiction’’ in favor of ‘‘abuse’’ and ‘‘dependence’’, the concept remains prevalent in the treatment system. We conceptualize the network of services as an ‘‘addiction treatment system’’ rather than a ‘‘recovery system’’ since ‘‘recovery’’ is linked more narrowly to Alcoholics Anonymous and the 12-Steps and does not reflect other models that inform programs within the system. In the remainder of the paper we first review the literature on the welfare state, noting that the current context is marked by pluralism. We then provide a conceptual framework that claims the existence of three overlapping imperatives that characterize the evolving welfare state. Next, we outline our qualitative, case study methods embedded within the context of three Canadian cities (Winnipeg, Hamilton and Toronto). In the analysis, material from the case studies is filtered through the three conceptual claims. Finally, we offer a concluding discussion. The new welfare pluralism There is now widespread agreement that the post-war Keynesian welfare state, marked by universality, de-commodification and escalating benefits, has been eclipsed in Anglo-Saxon nations (Jessop, 1993; Peck, 2001b). This fatal decline was embedded in the demise of Fordism, the rise of competitive neoliberalized globalization and its downgrading of national sovereignty, and the fiscal crisis of the state. It involved a process of ‘‘rolling back’’ the welfare state through a variety of strategies: (1) discrediting of national welfarism as a system and an ideology; (2) dismantling outright certain welfare state programmes; (3) devolving ‘‘knotty problems’’ to the local level; and (4) privatizating and deregulating former responsibilities to commercial or nonprofit entities (Peck, 2001a; Peck & Tickell, 2002). These strategies have produced a ‘‘hollowed out’’ welfare state, generally hostile to redistribution and universality, magnifying rather than offsetting inequality, and epitomized by the 1996 U.S. welfare reform and the 1997 New Labour ‘‘Third Way’’ in the UK. Many view these trends in terms of neoliberalism, which Peck (2001a, p. 445) defined as the ongoing process to ‘‘abolish or weaken social transfer programs while actively fostering the ‘inclusion’ of the poor and marginalized into the labor market, on the market’s terms’’. Although there are differences in the ways that ‘‘actually existing’’ neoliberalism has taken form in Canada, there are also similarities. In Ontario, welfare state restructuring in the mid-1990s under the so-called ‘Common Sense Revolution’ drew heavily on neoliberal ideology, arguing for a break in the ‘cycle of dependency’ fostered by existing programs (Peck, 2001b). Peck and Tickell (2002) saw, from the 1990s onwards, and in response to some of the failings of the ‘‘roll-back’’ round of restructuring, a ‘‘roll-out’’ neoliberalism in which the welfare state is proactively deepening its interventions by re-regulating and micro-managing the poor through workfare, criminalization and labor market flexibility. Far from weakening, the state is seen to be robustly exercising its power, disciplining the poor by ‘‘enforcing [flexible] work while residualizing welfare’’ (Peck, 2001b, p. 10). These punitive pressures are seemingly producing a ‘‘mean and lean’’ welfare state (emphasis ours; Pinch, 1997). Moving from collective (even universalistic) rights to individualistic competition also places new demands upon individuals to be active consumers of the welfare state, or better yet, to actively do without the welfare state entirely (McDowell, 2004). The individual therefore emerges as both the problem and the solution in the new welfare pluralism (Cameron, 2007). This is predicated on the successful ‘‘opting out’’ of state-provided services (education and health especially) by those with sufficient wealth to exclude themselves, what Pinch

(1997, p. 38) called ‘‘self-provisioning’’ and what also is popularly known as DIY (Do-It-Yourself). The enhanced local variation unleashed in the neoliberalized, post-Keynesian era has engendered a welfare pluralism, in which a hodge-podge of semi-autonomous, highly variegated local welfare states shoulder greater responsibility for delivering welfare services (DeVerteuil, Lee, & Wolch, 2002; Peck, 2001b). This explains why the Keynesian welfare state’s successor remains conjectural and overlapping (Cochrane & Etherington, 2007), with no shortage of superceding terms: ‘‘Schumpeterian workfare state’’ (Jessop, 1993), ‘‘workfare state’’ (Peck, 2001b), ‘‘post-welfare regime’’ (Dean, 1999), ‘‘disorganized welfare mixes’’ (Bode, 2006), ‘‘post-welfare age’’ (Fairbanks, 2009) and so on. The lack of a coherent, agreed-upon welfare settlement does not mean, however, that we should not privilege the centrality of the state in orchestrating these changes, including its promotion of non-state actors. Wolch (1990) contended that the voluntary sector’s scale and scope had increased significantly since the demise of Keynesianism, as a way for the state to safely offload responsibilities and risk to non-state actors. More recent work (Fyfe & Milligan, 2003; May, Cloke, & Johnsen, 2006) has empirically extended Wolch’s observations on how the shadow state is an essential component of the state’s strategy of welfare pluralism. Others (Bode, 2006; Evers, 2005) have argued that arrangements between the welfare state and the voluntary sector are veering toward disorganization, volatility and hybridity. Finally, and critically, the lack of a coherent, agreed-upon welfare settlement cautions us against any totalizing accounts of welfare state restructuring that fail to appreciate the necessarily path-dependent, contingent nature of processes operating at local, regional and national scales, interacting with and emerging through inherited institutional landscapes. As such, welfare state restructuring rarely imposes itself without some unevenness and contingency, as each locale (and agency) filters broader tendencies through its own pre-existing ‘‘institutional layers’’ and local regulatory structures. Conceptual framework How can geographers better capture some of the momentous shifts and multiple realities inherent in the current welfare pluralism? Beyond geography as context, we need to make explicitly spatial claims about the new welfare pluralism that can be applied to various components of the welfare state. These spatial claims articulate that the different aims of the welfare state – ranging from therapeutic and containment to sustenance – produce different kinds of ethos, expectations and, critically, overlapping spaces that are understood and experienced differently by society at large, service providers and clients. Such an understanding could conceivably better capture a greater range of motivations and outcomes inherent in the new welfare pluralism than totalizing accounts of welfare state restructuring that downplay or deny the locally-contingent and piecemeal nature of the welfare state. In the context of this paper, we advance a specifically spatial claim that relationships between the welfare state, service providers, and clients can be understood with reference to three intersecting imperatives. We contend that each imperative comes with its own ethos, expectations and spatial practices that are manifest in, and reproduced through, specific sites associated with welfare provision. These sets of objectives may overlap but are not reducible to each other. For example, the programmatic objectives of therapy may overlap with the survival goals of the client (for example, seeking a place to stay and rest). Similarly, the therapeutic aims of shelters have historically coincided with the abeyance aims of moving visibly poor people off the streets. In this paper we are interested in understanding how the sites that

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comprise the addiction treatment system embody a shifting balance between these objectives, and the ways in which this balance, and the degree of confluence/conflict between objectives, reflects broader trends in the structuring and restructuring of the welfare state. Spaces of containment: the system acts as an abeyance structure The concept of abeyance plays out at the macro-societal scale, involving the ‘‘generic problem of a mismatch between the available positions in a society (too few) and the supply of potential claimants to those positions (too many).a variety of mechanisms have been devised to ‘absorb’ surplus populations and neutralize the potential mischief of idle hands’’ (Hopper & Baumohl, 1994, p. 530). These mechanisms have varied tremendously over time, including frontier settlements, public works, compulsory education, shelters and so forth (Mizruchi, 1987). The 1980s surge in the homeless presence in prime urban spaces, for instance, symbolizes the (residential) abeyance process gone awry (Hopper & Baumohl, 1994). Geography is crucial to the process of abeyance, with space taking on the role of containment and control. To Neil Smith (1996), Mitchell (1997) and Wacquant (1999), abeyance is narrowly framed by the state’s interventions to contain, punish, criminalize and evict ‘‘surplus’’ populations (especially homeless people) from prime (urban) spaces. Abeyance is essential to the escalating vengefulness of measures directed at marginalized, unwanted populations, leading to what Mitchell calls the ‘‘post-justice city’’ in which redistribution has been superceded by incarceration and extermination. However, not all abeyance efforts are so evidently heavyhanded, and abeyance cannot itself be reduced to revenge (DeVerteuil, May, & Von Mahs, 2009). In some cases, abeyance (and broader service aims) are not wholly encompassed by Foucauldian concepts of ‘‘discipline and punish’’ but counterbalanced with a ‘‘kinder, gentler’’ intent that operates through agencies in the interest of clients. While the more totalizing (punitive) interpretations seem to dominate geographical understandings of current welfare pluralism, the next sub-section exposes the more therapeutic aims of operators, aims that belie the seemingly pervasive urge to control and contain clients. Spaces of care: the system reflects therapeutic aims of facilities From the point of view of the service operator, the provision of services to clients is a longstanding objective of the current welfare state. We can conceptualize these therapeutic aims in terms of ‘‘spaces of care’’, which Conradson (2003, p. 507) defined as ‘‘a sociospatial field disclosed through the practices of care that take place between individuals’’. Spaces of care are relational therapeutic environments designed to promote the well-being of the client. Central to this concept is that the welfare system –and particularly the voluntary sector – still retains some impulse to genuinely help people in need. The ‘‘urge to care’’ has persisted although its effects are largely absent from totalizing accounts of a punitive neoliberalism and post-justice city that have downplayed any benevolence within the welfare state (DeVerteuil et al., 2009). Geography and urban studies have recently begun to see spaces of care, an ethos of solidarity, and collective welfare as a worthwhile line of inquiry, as well as a bulwark against the rising tide of individualistic competition (Lawson, 2007; McDowell, 2004). May et al. (2006) noted that in the case of emergency accommodation, the more robust state interventions directed at regulating the voluntary sector and its clientele had not necessarily yielded a meaner service provision. Rather, there was continued evidence of more open-ended caring in the spaces of drop-in centers and

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soups-runs (Johnsen, Cloke, & May, 2005a, 2005b; Parr, 2000). This trend is mirrored in Parr’s (2000) examination of the ‘‘micro-social spaces’’ of drop-in centers for people with enduring mental illness, where she found such spaces operated as inclusive, safe havens for those individuals who are ‘‘othered’’ in mainstream public space (also Pinfold, 2000). But while Johnsen et al. (2005a, p. 787) see day centers as ‘‘important sources of material resources and refuge for a highly stigmatized group [homeless people]’’, they also warn against romanticizing such spaces, given that one person’s ‘‘space of care’’ could also be a ‘‘space of fear’’ for another (also Knowles, 2000). Indeed, our aim here is not to oppose the benevolence of service providers with the disciplinary intent of the state. Foucault’s later work on governmentality is useful in this regard as it directs attention to the ways in which organizational efforts to ‘‘care for’’ are imbued with a power to shape the conduct and subjectivities of those they serve (Fairbanks, 2009; Wilton & DeVerteuil, 2006). In this sense, the logic and practice of service providers do not exist outside of relations of power, but nor are they reducible to the broader objectives of the state. Rather they intersect in complex ways with both the macro-scale actions and interests of the state, and the mundane actions of individuals. Spaces of sustenance: the system acts as a critical node of client survival From the point of view of the client, the tension between spaces of containment and spaces of care overlaps with the more mundane demands of everyday survival across an increasingly diverse array of ‘‘nodes’’, including day centers, shelters, recovery homes, encampments, and so forth. The settings that comprise the welfare system – offices, drop-ins, food lines – can powerfully structure subsistence patterns, by ‘‘.defin{ing} daily paths.limiting social interaction to the institutional locale, and.providing material resources’’ (Rowe and Wolch, 1990, p. 197). Conversely, we can also detect in the search for ‘‘spaces of sustenance’’ the strong presence of client agency, a point recognized by Wiseman (1970). Using street-level ethnography, she was one of the first social scientists to recognize that clients redefined the system for purposes other than those intended by service providers. Hopper, Susser and Conover (1985) saw homeless people using shelters as permanent residential buffers in the absence of affordable housing, rather than temporary stepping stones to return to the mainstream. This trend led the authors to comment that ‘‘.the functions of public shelter are multiplying: that it is fast becoming not only a rough sanctuary for the utterly destitute, but an institute of trade, sustenance and even transient community for the sometimes working poor as well’’ (p. 21). As previously mentioned, little attention has been paid to the addiction treatment system in geographical terms, but also in terms of its relationships to the welfare state. We now turn to how these three imperatives are expressed in and through the spaces of the addiction treatment system (particularly detoxification programs) and the ways in which the shifting relationships between these imperatives – the degree of confluence/conflict between them – sheds light on broader trends in the structuring and restructuring of the welfare state. Data and methods Our methodological approach is largely qualitative, given that we are interested in the actual workings of the addiction treatment system and the everyday experiences of staff and clients within that system (see Fairbanks, 2009). In comparison to other studies of welfare systems (e.g., Mohan, 2003; Moon, Kearns, & Joseph, 2006;

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Peck, 2001b), our approach is more intensive, grounded and finegrained. Given that the hallmark of the new welfare pluralism is the multiplicity of localized welfare settlements, we pursued a multicity approach, investigating the treatment system across three Canadian cities (Winnipeg, Hamilton and Toronto). These sites were chosen in large part because of the researchers’ familiarity with, and proximity to, the cities. Finally, our approach acknowledges Burawoy et al.’s (1991) concept of the ‘‘extended case study’’, in which micro-spaces and the micro-world interact and are mutually constituted, all in an effort to reconstruct existing (welfare state) theory. This study was part of a larger project on how the built environment, internal spaces and neighborhood characteristics impact upon the ability of treatment programs to help their clients deal with addiction. Data collection involved participant observation and in-depth interviews with staff and clients at treatment programs in Winnipeg (Manitoba), Hamilton and Toronto (Ontario). We concentrated on researching treatment programs within the public sphere (i.e. not private fee-for-service organizations), and used a purposive sampling strategy (Curtis, Gesler, Smith, & Washburhn, 2000) to identify participant facilities, seeking a locational cross-section of facilities, ranging from those in downtown to more suburban locations, as well as a crosssection by client population and program focus (e.g., gender, treatment philosophy, religious/secular). Program directors, as well as frontline staff, were interviewed between Fall 2004 and Winter 2006 about client demographics, the physical and sociocultural character of the facility, its relationship with the surrounding neighborhood, the challenges faced in assisting clients, as well as changes to the program and neighborhood over time. Over the same period, clients at multiple sites were interviewed about their in-program experiences, as well as their knowledge of, and movement through, the broader treatment system. In total, approximately one hundred interviews were conducted with staff and clients by four researchers. All interviews were recorded, transcribed and analyzed using the qualitative coding software, NUDIST (N6). Overt participant observation at multiple sites provided a second form of data, with access negotiated with the program directors. While some observation occurred during daylong site visits, researchers also spent one or more weeks at some facilities, interacting with clients and staff, and sitting in on treatment sessions. Extensive field notes were taken during observation, and these were fully transcribed for analysis. For the purposes of this paper, we bracket our analysis to focus only on detoxification programs. There are both practical and conceptual reasons for narrowing the focus. Practically, the volume of data collected and the scope of the treatment system meant we could offer only a very superficial analysis of the system as a whole in a single paper. Conceptually, detoxification programs offer an ideal focus for this analysis because, as we demonstrate below, their origins can be linked explicitly to the confluence of imperatives for care and control of ‘‘public inebriates’’ in the post-war period. As such they provide a setting in which the shifting balance between abeyance, care and survival can be readily elevated for the purposes of analysis. Six detoxification (or detox) programs were included in the larger project, with a total of seventeen interviews conducted with program directors, staff and clients at these sites. Site visits were conducted at all six programs, with extended observation possible at two of the programs. In addition, clients interviewed at other treatment programs were asked about prior experiences of detox during their interviews. Since there are a limited number of detox programs in each city, many respondents had experience with one or more of the six sites.

Fig. 1. Key nodes within & beyond the treatment system.

In the sections that follow, we first outline the basic structure of the addiction treatment system before moving on to describe the system in the context of each city featured in this research. From there, we present a detailed analysis of the detox as one site within the treatment system, with particular attention to the shifting relations between abeyance, care and client survival that characterize this site in the context of welfare state restructuring. Understanding the addiction treatment system Fig. 1 provides a general representation of the key sites that make up the addiction treatment system in many North American cities, as well as other sites that connect to the formal treatment system. The formal system is typically comprised of four program types. Detoxification or detox programs (also known as withdrawal management) assist people with the acute stages of withdrawal from drugs or alcohol. Many programs are operated by non-medical staff and are located in community settings. Others are medicallybased and may be physically located in or near hospitals. The latter cater predominantly to people attempting to detox from alcohol and other drugs with significant physical symptoms associated with withdrawal. Traditionally detox has been operated as a residential program, but research and policy over the past decade or more has stressed that day programming (attending the detox during the day but returning home at night) or community-based withdrawal (withdrawing at home with the support of a case worker) can be as effective for people if they have secure housing and social supports in place. Three of six detox sites included in this research had introduced some form of day/community programming. Treatment programs provide structured environments and educational/therapeutic programming to help people learn to deal with their addictions. Some may be organized entirely around the 12 Steps, while others may combine the 12 Steps with other approaches (e.g., cognitive-behavioural therapy, relapse prevention). Recovery homes offer structured, abstinence-based living environments for people in the early stages of recovery from addiction. Unlike treatment programs, they generally do not provide any formal programming on site although they often mandate residents to attend a specific number of 12-step meetings

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as a condition of residence. They also normally require residents to be out of the house during the day, working, seeking work, or engaging in other appropriate activities. Finally, shared ‘sober’ housing offer long-term drug and alcohol free living environments for people. These living arrangements can be formally coordinated by an organization, but they are also provided more informally by other individuals in recovery. Although the organization of the system suggests a standard pathway for treatment – initial detoxification, followed by structured treatment, a stay in a recovery environment, and then longerterm sober-living – the reality is that people enter, navigate, leave and return to the treatment system in different ways. These trajectories reflect diversity among clients in relation to their gender, how long they have been drinking and/or using, whether they are housed or not, their prior experiences in the treatment system, their beliefs about what type of help they need, and whether they have had contact with the criminal justice system. Beyond the formal treatment system, other sites figure prominently in the lives of clients we interviewed. As Fig. 1 illustrated, these include a variety of more or less precarious housing arrangements, as well as homeless shelters, the streets, spaces of health care (e.g., the emergency room) and sites within the criminal justice system (e.g., local jails, as well as provincial and federal prisons). Again, relationships between these sites and the formal treatment system are characterized by a mixture of cooperation and conflict, the precise balance of which may be subject to change as new policy initiatives take effect. For example, detox sites have traditionally provided an important safety valve for both police and emergency room staff seeking to expel homeless people with chronic health and addiction problems. However, as we illustrate below, recent efforts to rethink the objectives of these programs (e.g., introducing longer stays and a greater focus on assessment and pre-treatment) may reduce the capacity of these sites to absorb flows of clients from other spaces. The treatment system in context While each city’s addiction treatment system reflects the confluence of local, provincial and national forces, a number of general statements can be made. First, the systems in each city are marked by a lack of inter-agency coordination, as well as weak funding streams that create disarticulated and over-burdened systems. Second, most facilities in the three cities remain disproportionately clustered in more accepting inner-city locales, although the picture is complicated in Toronto by the fact that several agencies are located in central city neighbourhoods that have experienced marked gentrification in recent decades. Third, there are a number of important similarities and differences between the cities in terms of client characteristics. In all three cities, clients are disproportionately male and predominantly low income. The treatment system itself has historically been geared more toward the needs of men with addictions and the current capacity of the systems in each context reflects this male bias (e.g., Swift & Copeland, 1998). In terms of income, and notwithstanding the universal availability of public treatment in the Canadian context, people in the (public) treatment system tend to be poor, as people with private insurance often elect to use private fee-for-service facilities. However, recent policy changes have arguably begun to shift the system’s focus away from lowincome and indigent clients. This is particularly evident in Ontario where policy has prioritized an expansion of community-based treatment options at the expense of more costly residential treatment capacity (OSAB, 1999). Proponents have argued that community-based treatment can offer earlier interventions and more flexible treatment options before people lose jobs or sever

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social ties. However, clients using these treatment options need to have secure housing and informal social supports, meaning that they are less well-suited to indigent people with chronic addictions who have fewer supports and no access to safe housing. Winnipeg is distinct because it has a significant Aboriginal population (ten percent of the city’s population) and Aboriginal people are over-represented in the city’s treatment services; estimates suggest that up to 75 percent of clients of the treatment agencies in Winnipeg claim indigenous heritage. Toronto and Hamilton have much smaller Aboriginal populations (0.5 and 1.5 percent respectively) and programs reported only a few Aboriginal clients. Both Ontario cities are ethnically diverse due to immigration, although treatment providers reported that their clients remained predominantly native-born white (and to a lesser extent Black) Anglophones, with some small increases in use by other populations. There is also variation within and between the cities with regard to the service philosophy and objectives of different providers. This variation reflects the gradual, and to a large extent piecemeal, emergence of organizations that comprise the treatment system in each city (Roberts & Ogborne, 1999; Wilton & DeVerteuil, 2006). It also reflects the differing responses of organizations to new trends in treatment and new state directives. Recent years have seen two distinct but related emphases in treatment policy. The first is a move away from any single treatment approach toward a ‘‘clientcentered’’ model recognizing that different approaches may work for different people in need. Implicit in this move is a critique of programs that adhere exclusively to the 12 Steps. Policy has encouraged adoption of harm reduction to complement more traditional abstinence-based treatment, thereby creating a more flexible system. Harm reduction emphasizes, among other things, the importance of smaller steps in the treatment process – for example, reducing drug/alcohol consumption or using drugs in a safer manner (see Des Jarlais, 1995). However, the call for flexible client-centered approaches has had limited impact in practice. In all three cities, a majority of treatment providers remain abstinencebased. The second emphasis concerns the need for ‘‘system integration’’, with emphasis on collaboration among agencies, mergers to create multifunctional organizations, and greater system efficiencies. Again, this strategy has been pursued more aggressively in Ontario, where provincial policy contends that integration is an essential step to ‘‘use existing resources to help more people’’ (OSAB, 1999, p. 9). However, uptake of these initiatives has been uneven across treatment systems, with some agencies actively resisting change and others embracing new policy initiatives. These actions reflect differences of opinion among providers as to how best to approach addiction treatment. As we illustrate below, these differences are critical to an understanding of how different organizations work for and/or against broader state imperatives. They also have significance for the extent to which the daily routines of organizations align or conflict with the survival practices of clients. Efforts to foster greater integration within the treatment system also brings with it the potential for a shift from loosely connected individual program sites to a more formally organized ‘‘system space’’. In Ontario, this move is embodied in the creation of DATIS (Drug and Alcohol Treatment Information System), which is intended to collect real-time province-wide data on program availability to facilitate referrals and effective use of resources. DATIS is consistent with the policy objective of in developing an integrated system of services, although there has been resistance from some agencies because of additional work required for reporting and concerns about loss of autonomy. The creation of an integrated system space may also have implications for how

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Table 1 Profile of detox sites Site

Location

O1 O2 O3 O4 M1 M2

Community Community Community Community Hospital Community

(hospital (hospital (hospital (hospital

affiliation) affiliation) affiliation) affiliation)

(stand-alone)

Clients

Mode

Program

Capacitya

Avg. stayb

Women Men Men Men Mixed Mixed

Non-medical Non-medical but RPN on staff Non-medical Non-medical Medical Non-medical

Residential Residential Residential Residential, day & community Residential & community Residential

10 26 22 30 11 25

6 days 4.5 days 10.5 days 8 days 6–7 days 7–10 days

a

Capacity includes both observation beds where people are placed upon arrival, and regular beds to which clients are transferred once they have stabilized. b Average stay figures for the Ontario programs were obtained from a report prepared for Addictions Ontario (Cathexis Consulting, 2005). Figures for Manitoba programs were based on estimates from program directors.

clients use programs. Provincial policy states that system integration will ‘‘ensure that clients can move easily from one part of the system to another’’ (OSAB, 1999, p. 7) but one might ask what type of movement is envisioned here. Some clients move through the system from initial contact to successful outcome, but others – for example, homeless people with chronic addictions – move around the system over extended periods of time. As we demonstrate, the creation of a more integrated system space has the potential to restrict certain types of movement while facilitating others. Understanding the detox as a space of abeyance, care and survival Our aim is to now explore how detox programs function simultaneously as spaces of control, care and client survival, as well as the extent to which these different functions conflict with and/or mutually reinforce one another. We are particularly attuned to the fact that ongoing efforts to restructure the addiction treatment system, as well as broader changes to the welfare system in each context, may alter the balance between these functions. We are also mindful that organizations, staff and clients may embrace and/or resist such changes. Table 1 summarizes the characteristics of the detox programs included in this research. The following quote from the director of a women’s detox is a useful starting point for the analysis as it provides one example of the way in which the imperatives of abeyance, care and client survival may intersect within a given program space: We had a woman that came in last night, via the police, and she’d had twelve beers, she was quite entertaining actually. It’s hard to know whether or not she’ll be here this morning. We know her and so she’d normally stay until the morning and then she’d be out of here or she may stay for a week. So we gave her an outfit to wear, we had ice on her head when she got here. We were glad to see her and when the next shift came on, they were glad to see her. Some of our team are smokers so they went and sat with her while she had a cigarette. Who knows how much of that she’ll remember in the morning. Hopefully what she remembers is that she had a positive experience while she was here (O1, director) The woman’s contact with the program was a product of law enforcement’s response to an instance of public intoxication. The detox offers a spatial fix, allowing police officers to remove the individual from public space while at the same time avoiding arrest and incarceration. At the same time, the program offers a space of care, where staff members ‘‘were glad to see’’ a woman they believe to be struggling with addiction. Finally, the site can be understood from the client’s perspective as a space of respite, where she can sleep safely for one or more nights, acquire food, clothing and basic health care, and find support. However, the balance between these three objectives is not always as congruent as this example would suggest.

Abeyance Like much of the formal addiction treatment system, detox programs can be understood as a product of the post-war period, emerging both as a response to the immediate needs of alcoholics visible on city streets and as a space of control that could replace the city jail or the hospital emergency room. The emergence of detox programs was made possible in part by the rapid expansion of the Alcoholics Anonymous fellowship and the growing number of recovering alcoholics who began to organize services for others. Previous work has demonstrated the extent to which treatment programs emerged as ‘‘cottage industries’’ cobbled together by local activists (Wilton & DeVerteuil, 2006; see also Fairbanks, 2009). At the same time, the growth of detox services was facilitated by the expansion of spending on public welfare services in the post-war period. In some instances, sites were incorporated as units of larger health care organizations, although their operations were largely non-medical. In other instances, detoxes operated as stand-alone organizations. There has traditionally been a distinction between programs staffed by recovering alcoholics adhering to 12-Step practice and peer support, and those operating as medical detoxes, staffed by staff with professional credentials. Although addiction was not regarded as a legitimate illness within the formal health care system, state agencies recognized the utility of detox sites and provided organizations with resources to sustain and expand capacity. Program staff speak to these origins in the following statements: What happened was the community. [they] were having problems with drunks. Every morning when they went into the stores, they were lying in the doorways, you know, passed out. It would take the police an hour or 2 h to come to pick them up and they would take them to the drunk tank. That’s how we got into the business, was that we patrol Main Street, the bars. If anyone was picked up, we would take them out and eventually we ended up taking them to our office. (M2, founding director) At the beginning [detox] was set up for the police and the emergencies. People with specifically alcohol problems were on the streets and there was no place to take then other than the cells or the emergencies. This was like a savings for both the police departments and the hospitals in terms of the utilization of emergencies and the police cells. At least when they [clients] come here we are able to do something with them in terms of helping them with their withdrawal. (O3, director) In this sense, the detox functioned as a relatively inexpensive containment space for public inebriates, but also as a space of care infused with a shared understanding of the challenges of addiction. This does not mean that these objectives were always compatible with one another. For example, the interests of police in removing ‘public nuisances’ may not always fit with the therapeutic objectives of detox staff or the limited capacity of many programs.

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In the contemporary period, detox sites continue to operate in this abeyance role. Programs continue to receive indigent and homeless clients brought in by police or transferred from hospital emergency rooms. As one director remarked: [Int: Do most clients know where you are and just show up?] Yes, also the Police and a lot from the emergencies [Int: because they know where you are?] Yeah, and they don’t want these guys around there I assume. Related to this, staff commented on the exclusionary pressures that such clients face in mainstream health care settings. For example: The hospital, I know that there’s still the stigma. I mean when I go to emergency, you know, ‘Oh, that one’s for you’. So you know, that kind of stuff.I don’t think that they get treated as well as they should, you know, ‘they’re not the real sick people’ (M2, staff, emphasis added) Detox programs also provide a safety valve for staff at other sites such as ‘‘dry’’ homeless shelters and abstinence-based addiction treatment programs when they are confronted with a client who is drinking and/or using. A worker at a ‘‘dry’’ shelter in Toronto, for example, described what happens if a client doesn’t return to the shelter at night because they have relapsed: We have a lot of cases that will phone the next day, all regretful about what they did the night before and they would like to come back and the only option available to them then is ‘you get yourself into detox, you stay there for four days and we’ll bring you back’ (Shelter worker, Toronto) To the extent that detox programs can absorb flows of clients who have been ejected – permanently or temporarily – from other service sites, they work to prevent these individuals from becoming ‘‘problems’’ in public space (Smith, 1988). Care Alongside this abeyance function, program staff understood these interventions as important therapeutic contributions in moments of crisis. For example, a program director commented on the role of the detox in preventing clients who had relapsed from falling through the cracks of the system. If a client relapses and is really struggling and needs two days in here, we move him in here just until he can get refocused.At every meeting I go to, I rant a lot ‘okay, if a guy relapses, send him here overnight, we’ll stabilize him. Don’t lose his living environment’ (O4, director) This quote provides an example of shifting approaches in treatment. The director’s view that relapsing clients can be moved to detox, stabilized and then returned to treatment is informed by a harm reduction approach. By contrast, some abstinence-based programs would see relapse as grounds for immediate expulsion. The extent to which staff at specific detox programs are currently willing and/or able to fulfill this combined abeyance/safety valve role is shaped by two factors. The first of these is capacity; interviews and provincial records on usage suggest that programs are typically operating at 90 percent of their capacity or greater on average so that they may often be unable to accept new clients when approached by police or emergency services. Second, the extent to which programs are willing to function in an abeyance role is influenced by a number of factors, including the broader state funding and welfare policy, as well as the shifting therapeutic objectives of individual providers.

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At one extreme, a community-based detox in Winnipeg contracts with the municipal government and the police department to run a ‘‘drunk tank’’ in the same location as its detox program. The drunk tank operates under the auspices of the Intoxicated Persons Detention Act (IPDA) which permits police to detain visibly intoxicated persons deemed to be causing a disturbance in public space. Essentially, this results in a non-profit organization operating a drunk tank in concert with local police. Read critically, this raises difficult questions, not least because the IPDA is used to regulate the movement of problem individuals (typically homeless people) in the downtown area. However, the director argued that funding for this program was critical to the overall survival of the organization. We get money from the Police Department for IPDA and that’s on a per admission basis and that’s our cash cow .because we can use that money however we want to, that’s our flex money. (M2, director) Staff at the program also argued that it was more appropriate for them to operate this facility rather than leaving it up to police and/or private security employed by the local business improvement zone. From a therapeutic perspective, staff members believed the co-location of the drunk tank and the detox program constituted an opportunity to begin to engage people struggling with addictions. As one of the frontline staff explained: We have the drunk tank. We keep you for up to four-hours or longer until we say you’re sober and then we let you go home. The whole point to having the IPDA there is when we’re releasing you we tell you about all of our services. We tell you that we have a detox, and a hostel, and a transition team, and most people don’t immediately do that but they hear about us. The idea is to get the people crashing and get them to trust us and just have an idea that people care (M2, worker, emphasis added) The organization’s attempt to build relationships of trust with people in the IPDA unit also reflects its broader approach to treatment and engagement with clients, which does not insist on an immediate willingness to pursue formal treatment. This approach combines short-term assistance for people who have gone ‘‘off the rails’’ (sleep, food, conversation) and a longer-term goal of trust and the potential for change and formal treatment. In this sense, the program constitutes a complex space of abeyance and care, shaped by state funding policies, revanchist tendencies in the local urban environment, as well as the enduring commitment of the organization to offer a tolerant environment for indigent alcoholics. At the other extreme, some programs have deliberately moved away from a more traditional abeyance function. The motivations for this change come from a combination of state agenda and changing provider priorities. As we noted above, Ontario’s Ministry of Health has initiated a rationalization of funding for addiction services and encouraged a focus on ‘‘best practices’’. For detox, this has a meant a shift to a model of withdrawal management with greater emphasis placed on programs as entry points to a larger addiction treatment system, and not as a place for temporary respite and/or restraint. This move has been supported and embraced by some programs eager to see professionalization of service and a more active role for detox in the treatment system. For example, the director of a men’s program spoke critically about the operation of the detox in its previous incarnation: It was a very short stay. Come in, get sober, out you go. length of stay was about three days. It wasn’t a very clinical setting. There were no formalized assessments done. It was just bring them in, clean them up, and ship them out. (O2, director)

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For the director, the old model essentially did little to help people, with a revolving door policy and little or no requirement for clients to do anything while on site. The new model emphasizes longer stays with participation in on-site programs and the completion of provincial assessment tools as requirements for residency. At this program, the director had initiated a fundamental reorganization of service according to provincial best practices several years earlier. This involved the temporary closing of the site and the turnover of all existing staff, a majority of whom had been proponents of the 12-Steps model and resistant to the new priorities. By contrast, the new staff was comprised predominantly of younger workers with professional credentials. Significantly, the changes had diminished the program’s ‘‘abeyance’’ capacity. Prior to our closure, Police were our number one referral. When we reopened the program, ‘self’ became the number one referral. the number of Police referrals decreased dramatically because we started to have ‘no-bed’ situations. They would call and we didn’t have a bed so that person ended up either going into the shelter system if they had nowhere to take them, or they ended up going into the holding cell until they were sober and then released (O2, director) This statement can be read as a ‘‘push back’’ against the existing role of the detox for law enforcement or emergency room staff seeking to move on problem clients, and the expansion of a more professionalized therapeutic capacity. Longer stays, more formal programming and more intensive case management reduce the capacity of the detox as a ‘‘drying out’’ site and necessitate other flows of people – for example, to homeless shelters or police holding cells. These changes are part of a broader reconfiguration that includes both reworking the function of residential programs and an exchanging of residential capacity for community-based and ‘‘daytox’’ capacity. In Winnipeg, the hospital-based detox had its residential capacity cut from thirteen to eleven beds, with the concomitant introduction of a community withdrawal management program. In Toronto, efforts had been made by the provincial ministry of health to restructure the treatment system with the proposed closure of two inner-city residential detox programs and the concurrent expansion of community-based withdrawal management capacity. The closures were put on hold after protests by unionized workers and clients who argued that the expansion of non-residential options would not help homeless and precariously housed people (Palmer, 2005), although the programs’ future remains uncertain. Client sustenance The shifting priorities of some providers also interact with the survival strategies of clients. Of central relevance here is evidence that a therapeutic focus on best practices and the preparation of clients for the next step in addiction treatment works to make the detox more conducive to the survival needs of some clients, while limiting its potential for others who are not ready to pursue treatment (or at least are unable to present themselves as such). Efforts to extend the therapeutic mandate of detox programs – especially their role as conduits to the larger treatment system – means that many programs offer extended stays to precariously housed or homeless people waiting to get into residential treatment programs. This practice reflects staff members’ recognition that waiting lists at many treatment programs make it difficult for these clients to find a space quickly. As a consequence they may have to return to unsafe environments after detox and face immediate relapse. In interviews, a number of clients who had moved on into

residential treatment spoke appreciatively of detox programs that had offered extended stays to keep them safe. For example: I did two years federally. Then I came out and I started using again. I discovered a new substance by the name of Crystal. I looked like death and finally I just thought, ‘This is insane. I need help’. So I went to a detox. At the time I didn’t know it but [name of detox] held on to me until I was in a safe place so I didn’t have to slip through the cracks again (Larry, TH, Toronto) I love [name of detox]. They were really fair to me. A year ago June I stayed for 29 days and I couldn’t have asked for a better place to be safe (Glen, TH, Toronto) This willingness to provide longer-term accommodation for some clients is particularly significant given the concurrent emphasis on reducing the residential capacity of the system and switching to community-based resources. The lack of residential treatment capacity in the system was a recurring theme in interviews. In one sense, the lack of capacity speaks to a fundamental tension between a policy objective of ‘‘moving people through the system’’ and a system which cannot accommodate client demand. More critically, it is possible to suggest that the shift from residential to community-based programming is intended to prioritize the flow of some people through the system (those who are housed, for example) at the expense of others. By offering extended stays to homeless and indigent clients seeking residential treatment, detox staff work against this prevailing trend. However, there is an emerging tension between treatment objectives and other clients’ need for temporary respite. As we noted above, there is significant variation among people using the treatment system in terms of demographic characteristics, addiction histories, and trajectories into, within and beyond the system. These differences are important since some clients’ needs are more closely aligned with the therapeutic objectives and day-to-day rules of treatment spaces than others. While detox staff appear to be bending the rules to provide safe spaces for poorly housed or homeless clients who demonstrate an active interest in pursuing treatment, many programs have become concerned about other clients who are not interested in using the detox as a stepping stone to more structured treatment. For example: A lot of people use the system inappropriately. They come here because they don’t like hostels. A lot of the workers in Toronto have sent people here just to get them out of their offices. They see us as an extension of the hostel service sometimes. They forget we are health care dollars (O4, director) This quote speaks to tensions between service providers, as the director criticizes staff at homeless shelters for referring clients to the detox primarily for shelter needs; something he sees as incompatible with its primary health care mandate. It also speaks to a tension between therapeutic objectives of the providers and the immediate objectives of some clients seeking a space of temporary respite away from the intense pressures of using/drinking and/or the stresses associated with unsafe living environments. For many clients, the detox offers a space to take care of oneself physically and emotionally. Many arrive in a state of physical and emotional crisis, and several days may be given over to acute withdrawal and recovery from the impacts of drug/alcohol use. For example: I was in the bubble [observation room] for almost four days. The first two days I was so grateful to get in. I got a cup of juice. then once I laid down, she put two blankets on me and that was it, I was out. Then Monday I woke up and managed to eat something but then I threw it up again. I slept all day Monday, literally 22 h or something. Then I woke up Tuesday and I slowly started to eat a little bit. I started with just cereal in the morning

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and that stayed down and then it got better. (Tom, O2, client) These places have saved my life time and time again. The staff are very compassionate and empathetic. It’s just a very warm, nice place (Charlie, O2, client) As Tom’s quote indicates, there is a need for some time to rest and recover from the physical impacts of drug and alcohol use. Charlie, a self-described 20-year veteran of the treatment system, points to the way in which the detox may be used repeatedly by people seeking temporary respite from the profoundly negative effects of addiction/use, even if they are not immediately interested in long-term abstinence. While detox programs are designed to meet these needs, recent changes have tied receipt of these services more closely to active participation in programming and evidence of a commitment to treatment. Clients recognized this expectation and its implications for their use of the detox. Charlie, for example, commented: Guys will come in and even though they get put upstairs, it doesn’t mean they necessarily want to go to a program. So they are going to be judgmental about the program. They are going to ‘‘f’’ the meetings [but] see you can’t just not go to meetings, you can’t lie in bed, you have to be down here. They will determine your length of stay by your eagerness to want to get better (Charlie, O2, client, emphasis added) During fieldwork we saw evidence that clients who failed to demonstrate an appropriate level of commitment to the therapeutic objectives of the program could be moved out of the detox more quickly. The following excerpt from field notes describes an interaction between a client and staff member during a group session at an Ontario detox: [Client] Dave said that last night he had woken up and couldn’t sleep. He had been shaking in his bed and so had gotten up and come down to the lounge to think. He said one of the night staff had found him and told him to go back to bed and hadn’t been interested in talking to him about his problems. [Staff member] Roy cut Dave off and told him he could speak to him afterwards. When we went back to the office, Sally asked how things had gone. Roy focused on Dave’s behaviour and said that they needed to talk about him. She said ‘well, let’s shut the door and talk’. Roy explained what had happened in the session and also commented that he’d had to go and get Dave from upstairs two out of three days. He said Dave wasn’t really interested in the program. Roy suggested moving up his discharge date (O2, field notes 6.12.05) However, as we noted above, not all organizations within the addiction treatment system have embraced recent policy changes. Indeed, some sites have deliberately attempted to maintain a focus on clients’ need for respite without an expectation that they will pursue formal treatment. If we can keep them dry for 10 days, that’s better than drinking for those 10 days so we’d let them in. They really didn’t have any plan in mind. (M2, worker) If they are fresh out of jail and have no place to go. They have no money and no place to go. In that way, it’s a safe place and yet it’s not [a shelter] (O3, director) Recognizing these differences in ‘‘therapeutic’’ response is critical for understanding the uneven nature of change within the system. More broadly, the recognition that objectives of abeyance, care and client survival objectives combine to produce spatially differentiated outcomes is important for an understanding of the regulatory richness (and diversity) of current welfare pluralism.

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Discussion and conclusions A central concern of the preceding discussion has been to illustrate the complex, multi-faceted nature of these treatment spaces, and the ways in which they are shaped by the intersection of sometimes mutually enforcing, sometimes discordant, imperatives. Detox programs, as a critical part of the treatment system, are interesting not least because their origins are explicitly tied to both an imperative for a spatial fix in relation to the control of an unruly population and a commitment to provide a space of care for people struggling with addiction. The detox also offered an important survival node for people seeking respite from drugs and alcohol. Understanding how these claims come together in different agencies, producing varied configurations of abeyance, care and survival ultimately cautions against totalizing accounts of current welfare restructuring. In recent years, there has been a reworking of this existing configuration. To some extent, this reworking reflects larger welfare state imperatives. The emphasis on detox as a starting point for active participation in, and movement through, the treatment system can be interpreted in light of the neoliberal emphasis on the ‘‘active citizen’’ as someone willing and able to participate in solving their own problems, a position that stands in contrast with the passive (and repeat) recipient of care in detox. Moreover, the reorientation of the treatment system away from residential options toward more cost-effective community-based programming may lead to disengagement with some clients (e.g., indigent and homeless people who do not have secure housing and stable relationships necessary to sustain them in such settings). In these ways, detoxes potentially separate out the most and least amenable clients, although this is not uniform across the system – service providers’ own evolving views on how best to provide care to clients cannot be entirely subsumed under, or reduced to, broader state imperatives, a point recognized by Lipsky (1980) in his study of street-level bureaucracies. At the same time, it would be a mistake to construe service providers’ objectives as being wholly at odds with the broader agenda of the state. The shift toward community and day programming, and efforts to more clearly define and enforce appropriate usage of existing detox resources are being driven by (some) providers’ efforts to improve and professionalize service, investing it with a more mainstream health care ethos. This shift is also informed by changing conceptions of how to most effectively shape the conduct and subjectivities of clients, and which clients are most amenable to these objectives. Together, these shifts have altered the balance between, and intersections of, abeyance, care and survival. Both state and provider-driven imperatives have reduced the more traditional abeyance capacity of sites like the detox. At the same time, these shifts have led to greater distance between the respite function of the detox site as conceived by (some) clients, and the focus on active engagement with people seeking treatment as conceived by some providers. This reconfiguration has implications for sites within and beyond the addiction treatment system, and the ways that individual clients move between them. Despite these increasing expectations of clients, our ground-level study of the addiction treatment system and its agency-specific outcomes leads us to argue that detoxes have not completely aligned themselves with the purported goals of the roll-out, punitive neoliberal welfare state. Elements of caring (and sustenance) remain strongly evident in the system, suggesting a reading of the (localized) addiction system as certainly ‘‘lean’’ but not single-mindedly ‘‘mean’’, a point sometimes left out of totalizing accounts of welfare restructuring. Yet this is not to suggest that agencies necessarily stand wholly in opposition to broader state objectives. While some organizations

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have indeed eschewed the more punitive tendencies of neoliberalism, the shifting practices of these same organizations can also be seen to align with other broader governmental objectives aimed at shaping the conduct of client population. Finally, our paper suggests the need to examine how these spaces and links to welfare state apply to the private, rather than public, recovery system, as well as other components of the public system. These settings might include the recovery and/or soberliving home, shelters, and treatment centers. Our paper also suggests need to focus more on the currently neglected intersection between political and health geographies, drawing inspiration from earlier critical scholarship (e.g., Dear & Wolch, 1987; Kearns, Smith, & Abbott, 1991). For example, this line of inquiry can usefully expose the contradictions inherent in a welfare state that simultaneously promotes health while making the vulnerable worse off through cuts to essential programs. Finally, we need to take seriously the increasingly normalized hybridity of social services as they both resist and accommodate welfare state motives, the pressures of market logics and the demands from civil society (Evers, 2005). Acknowledgements We acknowledge support from a SSHRC Standard Research Grant, for ‘‘Clean and sober places: Exploring the therapeutic landscapes of addiction recovery’’. We also wish to recognize the openness of detox operators, staff and clients in Winnipeg, Hamilton and Toronto.

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