In ‘Strangers to Ourselves,’ a Revelatory Account of Mental Illness

STRANGERS TO OURSELVES
Unsettled Minds and the Stories That Make Us
By Rachel Aviv
276 pages. Farrar, Straus & Giroux. $28.

Rachel Aviv was 6 years old when she was hospitalized for not eating. She was so young that she had never encountered the word “anorexia” before; it sounded to her like a kind of dinosaur.

Her doctors decided that she should be kept with the older girls with eating disorders, who taught her how to exercise obsessively and treated her like an “anorexic-in-training.” But Aviv soon started eating again and quickly lost interest in depriving herself of the food she had previously refused even to talk about (pronouncing the words had felt the same to her as consuming them). A year later, she would confide in her diary, “I had some thing that was a siknis its cald anexorea.” She explained that she had anorexia “because I want to be someone better than me.”

It’s a startling passage in the prologue of “Strangers to Ourselves,” but like so many of the stories in this intimate and revelatory book, the truth of it is real but incomplete. As an adult, having written a number of stories about people in extremis for The New Yorker, Aviv has come to “question whatever basic feelings existed in me before they were called anorexia.” Her medical records failed to present a “coherent picture” of why she stopped eating and drinking, but that didn’t stop the doctors from issuing diagnostic proclamations. “The original experience couldn’t be captured or understood on its own terms,” she writes, “and gradually became something that wasn’t entirely of our own making.”

By “our” Aviv is referring to the other people in her book. There’s Ray, who sued an elite psychiatric hospital that prided itself on its psychoanalytic approach for failing to make him better; Bapu, a wealthy Brahmin mother of two who repeatedly left her family in Chennai, India, to pursue the ascetic life of a mystic; Naomi, who was incarcerated for second-degree murder after throwing herself and her twin babies into the Mississippi River; and Laura, a Harvard graduate from a well-to-do family, who had been prescribed psychiatric medications since she was a teenager and decided — years later — to see who she was without the drugs.

We learn about these people one by one, with a chapter for each, so that Aviv can recount their lives in detail and therefore in full. She interviews doctors, friends and survivors; she reads her subjects’ journals in order to get a grasp on how they explained themselves to themselves. Aside from her candid reflections in the prologue and the epilogue, Aviv mostly hangs back, even though her own experience primes us — as maybe it primed her — to be alert to how stories can clarify as well as distort the mental distress that a person is going through.

Psychiatric explanations can be helpful and harmful, Aviv says. They pretend to a neutrality that can offer consolation but also condescension. Persistent colonial assumptions about the irrationality of Indian religions meant that some of Bapu’s doctors were disdainfully dismissive. “She was ugly,” one tells Aviv. “She was living like a witch, and looking like a witch.”

In Naomi’s case, medications helped with her psychosis, but psychiatric evaluations were also used against her. Naomi, who is Black, said that she had dropped her babies into the river in order to save them from a life of “inferiority, indifference and ridicule” in a racist society.The psychiatrists who first evaluated Naomi after her arrest decided that even though she talked about an impending apocalypse and living in another dimension, her remarks about racism were too astute for her to meet the legal bar for insanity. But as her release date approached, 13 years later, a psychiatrist concluded that she had not yet “achieved adequate stability”: “Now she was deemed unwell enough to be indefinitely detained,” Aviv writes.

Aviv’s narrative is so attuned to subtlety and complexity that any summary risks making it sound like she’s doing something she’s not. This isn’t an anti-psychiatry book — Aviv is too aware of the specifics of any situation to succumb to anything so sweeping and polemical. What she does is recognize the multiplicity of stories that attach to her subjects’ experiences, exploring a variety of interpretations instead of jumping at the impulse to explain them away.

“Strangers to Ourselves” delicately balances two truths that prove remarkably difficult to hold in tandem. We all have our own minds, our own experiences, our own suffering; we are also social creatures who live among others, and social forces have at least some bearing on how we understand who we are. Aviv suggests that we continue to cling to reductive theories about brain chemistry because “the reality — that mental illness is caused by an interplay between biological, genetic, psychological and environmental factors — is more difficult to conceptualize.”

Psychiatrists talk a lot about “insight,” or what one defined as “the correct attitude to a morbid change in oneself.”Aviv points out the professional presumption baked into the term, as if insight is supposed to measure “the degree to which a patient agrees with his or her doctor’s interpretation.” Aviv, for her part, finds more resonance in Keats’s notion of “negative capability” — the capacity to experience “uncertainty, mysteries and doubts, without any irritable reaching after facts or reason.”She admits how hard it is for her to sustain such patience for her own anxieties and preoccupations, but “Strangers to Ourselves” is a book-length demonstration of Aviv’s extraordinary ability to hold space for the “uncertainty, mysteries and doubts” of others.

Looking back on her hospitalization three decades ago, Aviv remains haunted by what happened to another girl in the ward, named Hava, who died in her early 40s from complications of bulimia. In her journals, the 12-year-old Hava showed plenty of insight about her condition, referring frequently to her “chemical imbalances,” whereas the 6-year-old Aviv “had basically none.”

But perhaps it was this lack of insight — “I never felt stuck in a particular story that others had created for me” — that made Aviv’s diagnosis feel more malleable to her, allowing her to pursue other possibilities. The divide between her fate and Hava’s was enormous but also porous. “There are stories that save us, and stories that trap us,” Aviv writes, “and in the midst of an illness it can be very hard to know which is which.”