Strangers to Ourselves: Unsettled Minds and the Stories That Make Us by Rachel Aviv explores the different ways in which people try to make sense of mental illness, both on an individual and societal level. The book tells the story of six different people who experienced mental illness, including the sociocultural factors that shaped those experiences. One of these stories is of the author’s own experience of being hospitalized at age six for anorexia nervosa.
The author is a writer for The New Yorker, and her journalistic background is very apparent in the stories she tells. Of the other five individuals whose stories were told in the book, two of them were still alive and directly interviewed by the author. One of these five was someone who had been a co-patient of the author’s during her childhood hospitalization.
The book opens with the author’s own story, then moves on to Ray Osheroff, who was a notable figure in the conflict between a psychoanalytical approach to psychiatry and an evidence-based approach. He had a lengthy stay for severe depression at an institution called Chestnut Lodge, where the treatment team insisted that psychoanalytic therapy was the only way he could get better. Although he was only getting worse, they refused to put him on medication. He later sued Chestnut Lodge for malpractice for not using evidence-based treatment, and the book explores the debate that this lawsuit sparked within the field of psychiatry.
Next up is Bapu, a deeply spiritual Indian woman who was diagnosed with schizophrenia. In telling her story, the author explores issues around spirituality and psychosis, culture, and the ways families respond to mental illness.
The story of Naomi Gaines, a Black woman who killed one of her children while psychotic, addresses how racism impacts how mental illness is framed and treated and how it impacts access to care. It also looks at the effects of deinstitutionalization, the large numbers of mentally ill people who end up in the criminal justice system, and the limitations of the M’Naghten Rule, which is the legal test that’s commonly used in the US to establish an insanity defense. In Naomi’s case, doctors didn’t feel that she met the M’Naghten standard, and her public defender didn’t think a jury would accept an insanity defense. The book also looks at the poor care that people with mental illness receive in prison. In Naomi’s case, while in prison for second-degree murder, her antipsychotic was stopped due to cost. Unsurprisingly, her mental health deteriorated, and she was put in segregation for two months.
Next was the story of Laura Delano, a woman who’d been diagnosed with bipolar disorder and later borderline personality disorder. She took 19 different medications over the course of 14 years. The author observes, “While Black women tend to be undermedicated for depression, white women, especially ambitious ones, are often overmedicated, in order to ‘have it all’: a family and a thriving career.”
Laura ended up going off of medication because of emotional and sexual numbness, and she had significant difficulties with withdrawal, which led to her getting involved in online communities of others who’d also struggled with psychiatric medication withdrawal. The book explores the ways that people relate to the medications they are taking or have stopped taking and how this can shape identity and the stories people construct about their illnesses. The author also contrasts her own experience with Laura’s—while Laura’s doctors had pushed meds, the author had been taught to see her illness as “a kind of stress reaction… In a sense, Laura and I were mirrors on which different faces of psychiatry had been reflected.”
The author also shares her own experiences taking the antidepressant Lexapro as an adult. It sounds like it was prescribed not because of a psychiatric diagnosis, but rather to help with psychological rigidity around feelings of inadequacy. It was initially intended to be for short-term use, but she felt better on it and worse when she tried to come off of it. On a low dose, the author writes, “I was not depressed, but I was less social, flexible, and spontaneous. It seemed I had reached my baseline personality.” She ended up deciding to go back up to the full dose, and she’s remained on the Lexapro for over a decade. She adds, “I also realize that I’ve endowed my pill of choice with mystical capacities—it contains the things I’m not but wish I was—and merely the idea of swallowing such a thing has healing power.”
It was interesting to examine my own reactions to this. I’m very pro-medication as an option for treating mental illness, but I must admit, I judged the psychiatrist who started her on the Lexapro. Why? In part, it’s because I’m into evidence-based medicine, and prescribing medication for something it’s not indicated for seems like poor practice, but there’s also a more personal element to the reaction. I think that’s at least partly because I take meds to try to get back some of the self that my illness obscures, and taking meds to be a different person from the self feels… backward, maybe? Or maybe I’m just envious of the idea of taking meds as a self-enhancer rather than in an attempt to stay alive and maintain some degree of functioning.
The book has a lot of detail, drawing on interviews with many people associated with each story. It’s impressive in terms of journalistic quality, although my personal preference would have been to leave out some of the details that seemed less relevant. Then again, that’s at least partly because I wasn’t feeling well when I read it. I liked the author’s approach of looking at the bigger-picture factors that came into play in each individual’s story and how this shaped the way these individuals and those around them understood the illness. Both the depth of investigation and the big-picture view make this a unique and fascinating book.
Strangers to Ourselves is available on Amazon (affiliate link).
I received a reviewer copy from the publisher through Netgalley.