Strangers to Ourselves: A Review

Farrar, Straus and Giroux, 2022

“Mental illnesses are often seen as chronic and intractable forces that take over our lives,” writes Rachel Aviv in Strangers to Ourselves: Unsettled Minds and the Stories That Make Us (FSG, 2022). “But I wonder how much the stories we tell about them, especially in the beginning, can shape their course.”

The wager of Aviv’s book—a series of haunting, finely drawn case studies involving psychiatric diagnosis, medication, and hospitalization—is that “people can feel freed by these stories, but they can also get stuck in them.”

The Story of One’s Illness

A contributing writer to The New Yorker, Aviv published an earlier version of her final chapter there as “The Challenge of Going Off Psychiatric Drugs.” Central to her focus on “the story of each illness” as it unravels across eras, nations, and languages is the “correctness” of the diagnosis itself.

But how that decision is reached, and why, involves assessments so varied and culturally determined they can include how the diagnosis is received and internalized; whether it accords with a patient’s or caregiver’s assessment; whether the symptoms that present at the time of diagnosis are interpreted with enough insight, including into what they might conceal; and whether, in hindsight, the diagnosis can be said to align with the treatment prescribed, given its long-term effects and potential harms.

In each case, much is shown to depend on the larger social and cultural context in which the diagnosis takes place—from the physician’s training and intellectual disposition to local disputes over the inherited psychiatric tradition (e.g., Western or indigenous), with patients and psychiatrists alike stranded and “torn between the twentieth century’s dominant explanations for mental distress—the psychodynamic and the biochemical.”

A core problem, noted at the outset, is that “psychiatrists know remarkably little about why some people with mental illnesses recover and others with the same diagnosis go on to have an illness ‘career.’” In trying to account for that blind spot, the book unavoidably confronts the limits of the field’s models and narratives, past and present. In Aviv’s thoughtful rendering, “The history of psychiatry is a chronicle of these sorts of crashes, one model of treatment, a source of promise, giving way to the next.”

Granular Lives, Generalized Experience

In its careful movement from the granular to the generic and generalized, Strangers to Ourselves extrapolates on the broader consequences of these disputes, not least as they influence and mostly worsen the suffering of the patients in question: Ray, Bapu, Naomi, Laura, Hava, and Rachel, the author herself.

The “looping effect” that the philosopher Ian Hacking once described as a hallmark of psychiatric diagnosis helps Aviv convey how diagnoses can be internalized and, via identification with a term or label, turned into self-fulfilling prophecies. A new diagnosis, Hacking writes, can change “the space of possibilities for personhood. We make ourselves in our own scientific image of the kinds of people it is possible to be.”

Given the marked expansion of the DSM, ICD, and other diagnostic manuals in the 1980s and 90s, the stakes for patients since are clearly high. “Over time,” Aviv adds of a process that repeats daily and worldwide with far-reaching consequences, “a willed pattern of behavior becomes increasingly involuntary and ingrained.” What if the diagnosis is faulty or misapplied? How should patients respond if, years after formal approval, a disorder remains shrouded in controversy?

Strangers to Ourselves retells the stories of patients who, in Aviv’s words, have “come up against the limits of psychiatric ways of understanding themselves and are searching for the right scale of explanation—chemical, existential, cultural, economic, political—to understand a self in the world.” The search for one straightforward diagnosis may be elusive, possibly self-defeating: “These different explanations are not mutually exclusive; sometimes all of them can be true.” Sometimes, also, the book shows, none of them can be.

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Diagnoses and Dinosaurs

Rachel Aviv / FSG, 2022

Strangers to Ourselves opens with Aviv’s account of her own early-age diagnosis and hospitalization for anorexia, a term that at age six she mistakes for a type of dinosaur. While her parents fight over an acrimonious divorce, the rigid control she exerts over her food intake can barely offset the chaos around her, though her psychologists call it a contributing factor. In words adapted from the historian Joan Jacobs Brumberg, Aviv describes herself as “recruited” for anorexia, though the illness never became a “career.” She adds, of a key stress throughout on self-definition, “It didn’t provide the language with which I came to understand myself.”

In the first of five broadly comparable case studies, the focus shifts to Ray Osheroff, a prominent and ambitious doctor in northern Virginia, whose 1982 lawsuit against the psychiatric hospital Chestnut Lodge turned into, as Psychiatric Times put it, a “showdown between two forms of knowledge.”

In a memoir he subtitled The Untold Story of One of the Most Shameful Scandals in American Psychiatric History (It Happened to Me), Osheroff lambasted the Lodge’s psychoanalytic emphasis on patient “insight” as a precondition for recovery. Drawn instead to biomedical popularizers such as Nathan Kline, who published From Sad to Glad in 1974, Osheroff declared: “There is little doubt that I had been suffering from a norepinephrine imbalance,” the favored hypothesis at the time.

The hypothesis led Osheroff to characterize his condition as “exquisitely treatable.” He was prescribed Thorazine and Elavil, respectively an antipsychotic and an antidepressant discovered in 1960.

But after three decades of polypharmacy, involving these and several more psychiatric drugs, Osheroff’s hopes of recovery were dashed. Chestnut Hill went on to settle the case out of court, even as it called Osheroff’s biological emphasis “disproportionate” and an evasion of responsibility. As Aviv extrapolates of his memoir and lasting depression, “Two different stories about his illness, the psychoanalytic and the neurobiological, had failed him.” But they had failed for rather different reasons, following quite different protocols and promises.

“Some Disarray in the Biochemical Tides”

In his 1974 bestseller, Kline attributed depression to “some disarray”—notably vague and open-ended—“in the biochemical tides that sweep back and forth within the body.” The emphasis meant that he could also advise patients, “Do not try to dredge up reasons” for the condition.

Likewise, Frank Ayd, who ran the first clinical trial of Elavil and published Recognizing the Depressed Patient in 1961, called the rise of psychopharmacology a “blessing for mankind,” but firmly insisted: “No advantage is gained by an intellectual understanding of the psychological aspects of the illness.” Patients were invited—sometimes required—to suspend disbelief otherwise.

At the time, Aviv writes, “faith in the potential of psychology and psychiatry seemed boundless.” But the biomedical approach also raised new problems for psychiatry—not just from adverse medical events, withdrawal syndromes, and sexual dysfunction, but from the single-minded, at times unrelenting conviction that “fluctuations in brain chemicals were at the root of people’s mood.”

The case studies that follow in Strangers to Ourselves are strikingly different, taking the reader to southern India, mysticism, and a schizophrenia diagnosis that seems dangerously misapplied and enforced; then to foster homes and psychiatric incarceration in Midwest America in which Naomi, an impoverished Black woman, receives diagnoses that are difficult to detach from her continued demand for racial justice and an end to the racism she has endured. In both chapters, the line between mental illness and what cultures view as rational and sane is notably hazy.

Privilege and Perfectionism

Aviv’s final chapter extends the focus of her New Yorker article on Laura Delano, a Harvard graduate beset by her family’s wealth, privilege, and perfectionism, whose extended withdrawal problems from psychiatric drugs have since led to years-long activism and engagement around deprescribing.

In the book version of the chapter, which includes extensive autobiographical material, Aviv is careful to stress that “Lexapro tracks closely with the development of my career. It also corresponds with the period in which my boyfriend and I decided to get married.” For these reasons, she acknowledges in this draft, “I told Laura that I was struggling with a slightly different dilemma: to continue as the person I’d become I needed a drug. I wanted my children to remember the version of me that took Lexapro”—a version of her that is apparently calmer and less easily thrown.

The revelation complicates related narratives about short- and long-term use, urging better assessment of the psychodynamic and biochemical, including in their combination, but also where extended use can, with some psychiatric medications, lead to dependency and withdrawal.

In Strangers to Ourselves, the models and narratives that psychiatry adopts are seen to fail repeatedly, with consequences that are fraught for patients. As Aviv observes, “The divide between the psychic hinterlands and a setting we might call normal is permeable, a fact that I find both haunting and promising. It’s startling to realize how narrowly we avoid, or miss, living radically different lives.”