At a very early age, Rachel Aviv began to contemplate what it means to be mentally ill. Dizzy spells led her to doctors who concluded she was anorexic; hospitalization put her in the company of older girls who, she writes, only exacerbated her illness. In her second-grade diary she wrote, “I had anexorea [sic] because I want to be someone better than me.” Is that feeling a chronic sickness, a childhood phase, a misapprehension of oneself, a consequence of misdiagnosis or mistreatment, all of it, or something else?
The profiles that comprise Aviv’s well researched, quietly provocative book, Strangers to Ourselves, all turn on her sense that the Western psychiatric establishment isn’t up to the task of understanding our minds — that we’re effectively still, if not in the Dark Ages, not too far advanced beyond the days of leeches and trepanning. And as the reflex to prescribe medication around the problem becomes more common, the path to understanding is only getting steeper. There is a disconnect, Aviv argues, between the psychiatric establishment and “the stories through which people find meaning themselves,” and no clear sense of how to close the gap, or whether some see the gap is worth closing.
To explore this, Aviv’s book is built around profiles of individuals. Each, in a way, is a storyteller, often with the precocity of Aviv’s second-grade self. Ray, who sued a therapeutic institution for effectively failing to make him well, wrote a memoir titled A Symbolic Death: The Untold Story of One of the Most Shameful Scandals in American Psychiatric History (It Happened to Me). Bapu, an Indian woman whose extreme religious asceticism estranged her from her family, wrote pages upon pages of journals and letters and poetry in an effort to explain and understand herself. Naomi, who was imprisoned for throwing herself and her twin toddler sons off a St. Paul, Minnesota bridge into the Mississippi River, killing one, filled pages obsessing over her background and the role that racism played in her various plights. Laura, a high-achieving middle-class woman, journaled her anxiety about “these extra layers of thought that others don’t have and that pull me farther and farther away from being human.”
Aviv is a staff writer at the New Yorker, and in a few regards she has chosen a very New Yorker-ish way of going about this research. Her subjects are thinkers and readers, relatable to the magazine’s own audience in many ways, unrelatable only to the extent that their thinking has led them into extreme behavior. Indeed, the book’s structure and subject rhyme, right down to the title, with Strangers Drowning, a 2015 book by New Yorker writer Larissa MacFarquahar about extreme cases of asceticism and do-gooder-ism. Like a lot of New Yorker stories, Aviv’s are rooted in current science while alert to its biases, especially around race and gender.
But Strangers to Ourselves also performs a rhetorical feat that you might call the Reverse Gladwell. Where Malcolm Gladwell infamously — sometimes exasperatingly — uses peer-reviewed sociological and psychiatric literature to essentialize human behavior, extrapolating it into cozy generalities, Aviv does the opposite. Her book complicates mental illness, particularizes it, questions psychiatry’s ability to provide a cure-all, or even a cure-many.
In the case of Ray, she offers a substantive example of how this has played out in the public sphere. A longtime patient at the Maryland institution the Chestnut Lodge, a facility that eschewed pharmaceutical treatments, Ray sued the Lodge in 1982 for “failing to make him better.” The case was, as one trade journal put it, “a showdown between two forms of knowledge.” Is drilling into our pasts the key to achieving mental balance? Or can we sidestep all that, find the proper mood-altering pill, and attribute our struggles to brain chemistry? The case, perhaps appropriately, proved inconclusive — the Lodge settled in 1987. But in Ray’s case and elsewhere, she amasses reasons for skepticism all around. There’s evidence that the Lodge’s approach to schizophrenic patients was no better than any other; findings that Western medicine can exacerbate mental illness; complaints about the fuzziness and fluidity of the DSM. Attributing mental illness to brain chemistry, Aviv writes, endures “because the reality — that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors — is more difficult to conceptualize, so nothing has taken its place.”
The agony of that reality is particularly acute in the cases of Bapu, who went on long stretches disappearing from her family to find spiritual retreats in the midst of a “god intoxication,” and Naomi, whose despair led her to murder and attempted suicide. Aviv focuses on Naomi’s childhood in Chicago’s Robert Taylor Homes — high-rise public housing steeped in dysfunction and violence. Despair over the feelings of isolation and persecution as a Black woman in part drove her to her violent act, she suggests; awareness of other Black women’s stories’ allowed her to reckon with it. After reading them, Aviv writes, “she suddenly had language to describe the kind of pain that had haunted her family for generations.” Standard-issue therapy and medications, on top of incarceration (she was charged and convicted of second-degree murder), without that additional awareness, seemed to stand in the way of healing. It made Naomi feel “obsolete” and that the interventions “missed their mark.” “Her delusions might not have taken hold so firmly if she hadn’t felt so alone,” Aviv concludes.
Perhaps. In this age of leeches and trepanning, who can say? A book that is framed around unsatisfactory answers to the questions of what makes us mentally well and unwell is inevitably going to feel a bit unsatisfactory itself. Aviv’s structure demands she proceed from anecdote; the fact that each of the stories is rich and compelling doesn’t change the fact that they remain stories, individual examples of an outsize challenge. But to the extent that these narratives expose the gap in our understanding — and our wishful thinking that we’ve closed it — Strangers to Ourselves is a valuable book. A good companion to it is George Scialabba’s 2020 book, How to Be Depressed. Based on the case notes of psychiatrists addressing his chronic depression, it reveals how frustrating the path to wellness can be, a life-long process of storytelling and med-tweaking that can lead to frustratingly modest gains, even as the wisdom of about the source of the illness remains stubbornly opaque.
Or you can reach for a more famous example, as Aviv does a couple of times: Sylvia Plath, who in her poetry, her novel The Bell Jar and her journals, demonstrated the depth of an intellectual/mental crisis, the uncertainty-bordering-on-futility of treatment, and its tragic end. Plath damned herself in her journal as a “SELFISH EGOCENTRIC JEALOUS AND UNIMAGINATIVE FEMALE,” and Aviv explores how much gender norms and expectations play in the diagnoses and treatment of mental illness. She describes how her experience on the antidepressant Lexapro shifted her outlook and productivity; she soon learned that she had a lot of company among high-achieving women in her circle, consuming what one friend called “Make the Ambitious Ladies More Tolerable Pills.” Is that tolerability socialized, gendered, connected to who we are as individuals? Aviv characterizes herself on Lexapro as better, but not necessarily herself.
Aviv presents none of this as a direct attack on psychiatry or psychopharmacology. Neither are frauds, but its practitioners are perhaps stumbling more in the dark that they let on. Even if we are making people “better,” we are living in a gap. One that can’t be closed simply with drugs, or treatment, or storytelling, or some combination thereof. Nor will it help to conclude that it’s all unknowable and throwing up our hands. The crisis remains. We can tell a million stories about where our minds are at. And a million stories wouldn’t provide the answers that those who are suffering need most.
[Published by Farrar, Straus & Giroux on September 13, 2022, 288 pages, $28.00 hardcover]