“STRANGERS TO OURSELVES; UNSETTLED MINDS AND THE STORIES THAT MAKE US” by Rachel Aviv (Farrar, Straus and Giroux, 2022) is a serious, captivating, in-depth exploration of six case studies (including the author) that probes the soul, the meaning of “myself,” “my identity,” personal agency, personal continuity, deviancy, dysfunctionality, and the impact of external factors of culture and authority or their rejection.
From our consensual perspective, each of the six has a serious, even disabling, mental illness. Thus this is a journey through the psychiatric world and its, mostly failing, therapeutic techniques, which at its worst seems unable to understand or deal with the severe disruption and distress felt by the people we come to know in this book, and at its best seems only to provide names and categories which the world and these patients use to understand themselves and formulate their personhood. While Aviv, through detailed and diligent investigation, brings us to know her subjects intimately, she seamlessly weaves in (often footnoted) references to literature, psychiatry, philosophy and medical history which raise deep epistemological questions about the self and the soul without being didactic. This is powerful food for thought.
We get to know our author and guide Rachel who, her parents divorcing when she was very young, briefly became anorexic and continues to have anxieties, but has a family, two children and a successful career.
We meet Hava with anorexia whom Rachel met during her first hospitalization and who never was able to transcend her inner turmoil, forever being an anorexic person. Yet in an endearing coda, Rachel tells how Hava found a partner and love and was building a life when she died of complications of her disease at a young age.
We get to know Ray, a trained physician and nephrologist, who, after being married and having professional success, lived a roller-coaster life of debilitating depression and anxiety. Even with periods of stability he was never able to rebuild his pre-morbid self-esteem and functioning.
In India we come to know Bapu whose internal compass led her to reject the reasonable psychiatric help available. Her forceful internal needs led her to become an exceedingly ascetic beggar, joining a temple. Is this a spiritual elevation?
The saddest story is Naomi, an obviously sensitive, intelligent and creative Black woman. Trying to care for her four children—including 2 newborn twins in deprived circumstances all too familiar to us—and afflicted either with what we would call postpartum depression or schizophrenia, her paranoia focusing on the transgenerational impossibility of security for her family, jumps off a bridge with her twins repeatedly yelling “Freedom” on the way down. She and one of her twins are rescued, only for her to spend decades in prisons and hospitals as a murderer and civilly committed as insane.
Finally Laura who comes from a well off family dragged down by depression, trying to seek liberation and herself through various medications and combinations of medicines, but never becoming a healthy person.
Each of the subjects would commonly be labeled “mentally ill,” and their symptoms generally are extreme. Aviv has wisely chosen them from differing social classes and cultures, demonstrating the universality of psychological dysfunction and its independence from intelligence, wealth, schooling and caring families. She shows the frustration supportive friends and families have when they can make little sense of what the problem actually is or have little impact, while adverse circumstances can make matters a whole lot worse.
Throughout Aviv pays diligent attention to the evolution of psychiatric knowledge and tends, and without being preachy or didactic clearly demonstrates how these apparently well meaning healers—many of whom she interviews—were unable to rehabilitate or rescue these souls.
One of the most powerful messages that comes from this book is that psychiatric labels and treatments can have tremendous impact on a patient’s self-regard and world view while at the same time having minimal impact on the existential improvement of the dysfunction.
But then, in a fascinating tour de force, Aviv goes deeper—perhaps based on insight into her own experience—to describe how these “dysfunctional” souls contemplate, create, understand and live out their own personalities, their sense of self—as chaotic as it might be—and struggle, with some success to have an identity within their illness. We feel sad as one patient anchors her identity on the diagnostic label her psychiatrist gives her—only to have the next psychiatrist give her a different diagnosis. At other times, this person anchors her self-esteem on the pill or pills she is taking which, helping or not, give meaning to her life.
Aviv quotes Thomas Insel, long time director of the National Institute of Mental Health, who laments: "Nothing my colleagues and I were doing addressed the ever-increasing urgency or magnitude of the suffering millions of Americans were living through—and dying from.”
This wonderful book brings us intimately into the chronic agony of mental dysfunction and its spiritual void, and reflects on the profound impotence and ignorance of psychiatric practice in treating serious or complex severe cases.