enjoyable to read combination of memoir, profiles, and witnessing
plenty of food for thought about the relationship between narratives, cultures, and mental illness
gives a broad-brush overview of some of the main movements within psychiatry, mainly since the 1960s
Towards the end of Strangers to Ourselves, we learn that Rachel Aviv has been on Lexapro, an antidepressant of the SSRI (selective serotonin reuptake inhibitor) family, for a decade. With a subtlety and nuance, she offers her opinion as to why that drug has been beneficial to her in her life in the United States — a life seen as made up of some (changeable) combination of ethnicity, gender, class, education, age, career, role, politics, religion, and geographical location. She has tried to come off the drug, but found that she prefers herself, and her life, with Lexapro in it. She finds herself to be a better mother, a better wife, a more successful journalist and author, a more productively social member of society — indeed, she wonders whether she would even be married, or have carried her children to term, without Lexapro.
Summarised, that might strike some readers as troubling, others as rose-tinted, and others again as validating and welcome. One of the key strengths of Strangers to Ourselves is that the book contains all those responses. Aviv is well aware that, in the US, antidepressants are prescribed to women, and particularly white women, in huge quantities; more than one in five white women in the US are on some form of antidepressant, and there is nothing particularly new about this kind of prescribing — Valium was the most commonly prescribed drug in America between 1969 and 1982, and 75% of prescriptions were to women. Like others, she wonders whether this is more to do with what a culture wants women to be, rather than about what might be best for women. As a friend of hers puts it, these could be seen as ‘Make The Ambitious Ladies More Tolerable pills’. She also wonders to what extent it is the pills that have so changed her life, rather than the changes in her circumstances, or the belief she invests in taking the pills. Joanna Moncrief’s recent article on the lack of evidentiary basis for the relationship between serotonin uptake and depression (Nature, 20 July 2022) is not disruptive of Aviv’s account, because that account is everywhere offered tentatively, as a series of propositions.
The main stories in the book are not Aviv’s, and offer less grounds for optimism than does hers; she places her experience of mental illness in the context of four stories of far greater suffering. The book’s chapters centre on: Ray, a white, 51-year-old nephrologist, in the Washington area, who has enjoyed considerable business success; Bapu, a wife and poet from a wealthy Brahmin family, in Chennai; Naomi, an African-American twenty-four year old mother of four in Saint Paul, Minnesota, who had grown up in the Chicago projects; and Laura, a white freshman student at Harvard from Greenwich, Connecticut. These stories of unsettled minds (as her subtitle has it), while not representative, are interestingly various. The protagonists in all four suffer great distress, and some of their stories include deeply disturbing events. The protagonists all have a variety of treatments and are offered many diagnoses, over a large span of years dating from the 1970s on. Some of these treatments and diagnoses change as psychiatry itself changes; read together, these four stories contain an informal account of the move from a largely psychoanalytic treatment of mental illness to one that is largely pharmacological, and which, more recently, is also beginning to be more consistently interested in social (in)justice. Within that broad sweep, landmark events and key concepts are noted and commented on.
The book’s chief interest, though, is in the stories offered to and told by those unsettled minds, and in thinking about how those stories interact with those minds and their suffering. As each story is read and placed beside the other stories, it seems that no single pre-existing medical or cultural narrative satisfactorily describes the protagonists’ sufferings or their lives. There are many moments when the protagonists seize on a diagnosis as if it offered a form of salvation, and yet, generally, after months or years, dissatisfaction sets in, and self-destructive behaviours, or simple distress, return. Aviv sees this in terms of a failure of psychiatric narratives to explain the individual’s experiences to her- or himself in satisfactorily meaningful ways. That failure then drives the individual to tell stories by, and about, this dissatisfaction – about how we may feel we are Strangers to Ourselves. Aviv’s key principle in selecting her subjects is that they have tried to give written expression to this feeling of dissatisfaction; and it is these stories which Aviv recounts. Her book is about ‘the facets of identity’ that the general narratives and theories of mind ‘fail to capture’.
Through each chapter, Aviv pieces together and contextualizes the several stories through which the protagonists seek to explain themselves to themselves. She draws our attention to the ways in which culture, history, gender, and ethnicity lead to differences in the narratives offered, and on offer, to those suffering. The differences in the narratives on offer may be prejudicial to the patient’s well-being; but Aviv is equally aware that offering the same narratives regardless of circumstance may also be damaging. The stories’ similarity of distress and variety of circumstances suggest that no single narrative or diagnosis or treatment in isolation is likely to help the sufferer — and indeed, in some cases, the narratives on offer may do damage, as the sufferers may become stuck within them, losing the creativity that may be necessary to find new stories with which to move forward in their lives.
The main stories of the book do not have happy endings, though their protagonists do generally obtain, over time, a somewhat better balance in their lives, so that their distress seems less wholly defining of them. Aviv’s reflections on her own story offer up no clear reason for the more productive nature of the medical interventions she experienced. She wonders if, in the case of her anorexia, she was – at age six – too young to really understand the medical narrative her illness and her doctors offered, and so too young to be trapped by it, unlike some of the other girls in her hospital ward, who were almost in their teens. One of these, Hava, provides the life-story for the epilogue. Unlike Aviv, Hava was fluent in the vocabulary of her disease, and demonstrated great ‘insight’ – that is the correct recognition of what, in medical terms, was happening to her.* Hava’s life remained largely trapped within her eating disorders, and her bulimia plays a part in her early death.
Strangers to Ourselves is, then, intelligently tentative, offering plenty of food for thought, and relatively little thesis. It is well written, as one might expect given that Aviv a staff writer at the New Yorker. At times it is pleasingly lapidary, inset with thought-provoking quotations, such as Winnicott’s ‘It is a joy to be hidden, but disaster not to be found’. Read whole, and given its interest in reading the various writings of its protagonists, it often has the qualities of a long Montaignesque essay. It records Aviv’s changing thoughts on mental illness and on her own relation to her life as she ponders different accounts of mental distress. In doing so, it establishes good grounds for Aviv’s sceptical refusal to commit to any single paradigm of mental illness.
Essayistic writing of this sort is often primarily personal and provisional; and it can often give the reader a better sense of the author’s values and habits of mind than those of the writers who are being read and thought about. One of Montaigne’s images of writing (and thinking) was of bees making honey; for the bee-like authors, the honey was theirs and the flowers were forgotten. (The image was originally Seneca’s; appropriately enough given the context, Montaigne makes no mention of his debt to the Roman author.) Such uses of flowers, and such notions of transformation and ownership, sit somewhat uneasily in a context where the flowers are the stories of the suffering of others, and the honey is an author’s money-making book. Readers of Aviv from a medical humanities background are likely to approach this book by way of Arthur Frank’s now classic account of the importance of narratives, The Wounded Healer: Body, Illness, and Ethics (1995). Aviv’s book fits within the framework of narratives that Frank describes. Strangers from Ourselves confirms the importance of narratives, both for good and bad. ‘Restitution narratives’, one of Frank’s three kinds, look much like the diagnoses on offer to the suffering individual, promising them the at least the possibility of a return to a normal life. ‘Chaos narratives’, by contrast, are seen to emerge at the onset of symptoms, or when the restitution narratives which are on offer are felt to fail – these are the times when sufferers’ experiences make little sense to themselves, and they feel their lives to be least intelligible. Most of the sufferers in Aviv’s book, in their writings, come to adopt the third of Frank’s narrative kinds, the ‘quest’, in which they experience a form of calling to testify to the value they find in their lives as they are, so that the value in their kind of life is seen by others. To Frank, it is vital that their voices sound out their experience in their own words; he defines ‘care’ often as no more, and no less, than an attentive and respectful listening to the stories of others. In a 2009 retrospective, Frank argued that the impact or ‘force’ of The Wounded Storyteller came from its practising of what it preached; it offered ‘witness’ to the stories of others. ‘The difficulty of writing such a book,’ he went on to say, ‘is balancing the authorial voice and the voices of those offering their testimony’ (Clinical Ethics, 4.2). Aviv generally strikes that balance; the distinction between flowers and honey is not forgotten as she explores her responses to stories of others’ suffering.
*Hava also leaves behind a written account of her illness. Aviv notes that she ‘found’ her book’s title in Hava’s notebooks, and takes the phrase to be Hava’s own. It may be; but it might also be another example of Hava’s fluency. Timothy Wilson has a book of the same title (2002) which deals with the difficulties of introspection. (Its subtitle is ‘Discovering the Adaptive Unconscious’.) And, presumably behind that title is the phrase (as it exists in translation) in Nietzsche’s On the Genealogy of Morality (1887 ): ‘We remain of necessity strangers to ourselves, we do not understand ourselves, we must mistake ourselves, for us the maxim reads to all eternity: “each is furthest from himself.”’
Other reviews
Page gathering together reviews
Recommended reviews: 'The Diagnosis Trap' (The Atlantic); 'Rachel Aviv's Journey to the Ends of Psychiatry' (Tablet); 'The Grubby Truth about Mental Health Memoirs' (UnHerd)
J. Lee, 2022 (medicine360.co.uk)