In Strangers to Ourselves, Rachel Aviv presents a series of portraits of mental illness, portraits that call into question a raft of preconceived notions about what it means to be considered insane. Aviv’s collection is one of the most evenhanded arguments for reconsideration of how we treat the mentally ill. It’s not a polemic against Big Pharma. It’s also not a call to ditch psychiatry wholesale. Instead, Aviv shows us that mental illness is just really complicated.
Aviv establishes her authority on the subject of mental illness by recounting her hospitalization—at the astonishing age of six—for anorexia. She has her childhood journals, interviews with family and doctors, and her own memories to illustrate the wide gap between her thoughts and what everyone around her speculates about her feelings and actions. Aviv’s illness doesn’t fit the definitions in the Diagnostic and Statistical Manual, used by thousands of mental health professionals to diagnose their patients, but we only know that because we have Aviv’s adult self looking back forty years later to point out the discrepancies between the Manual and her own state of mind. At six, Aviv wasn’t articulate enough or possessed of enough self-determination to clear things up with her doctors. And yet, while Aviv the girl had a troubling relationship with psychiatry, Aviv the adult has a more beneficial one that she tells us about at the end of Strangers to Ourselves, when she is prescribed an SSRI for her anxiety and depression.
Each chapter of Strangers to Ourselves profiles someone wrestling with mental illness and how they are seen and treated by others. (With one exception, all of the people in this book seek help from Western-trained physicians.) All present a different angle from which to view the complexity of mental illness and psychiatry. Ray’s story grounds a discussion of the battle between psychoanalysis and psychopharmacology as the discipline shifted from Freud’s model of mental health to a more medical view of brain chemistry and dysfunction. We see the inadequacies of any one-size-fits-all approach. Bapu’s tale is a particularly fascinating exploration of the fine line between deeply held faith and mental illness. Some societies (especially Western ones) have no space for behavior like Bapu’s (long pilgrimages, extreme fasting, incessant writing and praying, etc.) and call it schizophrenia. Naomi’s affecting journey reveals the literally maddening effects of racism and poverty in the United States. It questions the ability of mental health professionals of more privileged backgrounds to truly understand patients whose “delusions” of persecution aren’t actually all that deluded. Finally, Laura’s experiences are the opposite of Ray’s. Where Ray was treated with extensive psychoanalysis, Laura is given little more than a series of medications. She reaches a point where each new medication is prescribed just to counteract the side effects of her previous one.
Aviv’s book covers a little over forty years of psychiatry and shows us just how little we know about the brain and how it works. And yet, I wouldn’t say that Strangers to Ourselves is anti-psychiatry. Aviv and Naomi benefit from medication. Bapu improves when people take the time to actually talk to her, instead of dismissing her every word as insanity. Instead of argument, I see Strangers to Ourselves as a call for reflection. What treatments actually improve quality of life? Are we over-diagnosing and overmedicating? Would more of us benefit from talk or group therapy? Above all, I think Strangers to Ourselves shows us that helping people with mental illness requires a lot more than an hour on a couch and/or a prescription pad. It requires compassion and humanity. It requires a lot more flexibility to work with the highly individual manifestations of mental illness than is currently practiced in the West.
Strangers to Ourselves is one of the best books I’ve read about the subject and strongly recommend it to readers—especially readers who are or plan to work in psychology, psychiatry, and social work.