Reports from the Interior

Strangers to Ourselves: Unsettled Minds and the Stories That Make Us by rachel aviv. new york: farrar, straus and giroux. 288 pages. $28.
Rachel Aviv. Photo © Rose Lichter-Marck

When she was six, Rachel Aviv was hospitalized for not eating. Doctors concluded that she had anorexia, but now, decades later, in her new book, Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, Aviv is questioning that diagnosis—and many others. Her debut book concerns itself with people who occupy the “psychic hinterlands, the outer edges of human experience, where language tends to fail.” Strangers to Ourselves is that rare work that both elevates and remakes the form of writing about medical ethics. Each chapter is informed by Aviv’s meticulous reporting and draws from the deep well of her subjects’ diary entries, letters, and other unpublished material. The mongrel work combines personal narrative with stories of other individuals running up against the limits of psychiatry. These threshold figures include an Indian woman named Bapu, who was believed to be a saint with healing powers, and another woman, descended from Franklin Delano Roosevelt, who decides to stop taking prescription drugs after years of putting her faith in “these tiny pills and capsules” and feeling like the “living and breathing medium through which they did their work.” Another section tracks the experience of a Black woman who was dogged by thoughts that suggested it was “her job to save the world from racism”—and the ruinous consequences that follow. With the skill of an artist on whom nothing is lost, Aviv, a staff writer at the New Yorker, applies pressure to the idea of social deviance as mainly a medicalized problem, and offers a series of exquisitely etched, deeply humane portraits.

Aviv and I spoke over FaceTime in August about her new book. 

You’ve written many in-depth profiles of individuals who would seem to occupy the “psychic hinterlands.” You’ve written about Hannah Upp, a woman who went missing for several days and entered what psychiatrists called a dissociative fugue state, and another story about the difficulties of defining schizophrenia. But neither of those pieces is included in this book. How did you decide what to include and what to leave out? 

That was hard for me because I have certain criteria for what constitutes a story for the New Yorker, and I had to shift from that framework to a framework of, “How, if I tell this story, will it complicate or build on or challenge the ideas in the previous chapter?” The first story I knew I wanted to write was about Bapu. I had encountered her story many years earlier and had thought about writing about it for the New Yorker, but it felt too intergenerational and there wasn’t a clear news hook. There was one man whom I corresponded with for more than a year and hoped to write about in the book, but he decided he did not want to be in a book—but those conversations with him still really shaped the way that I was thinking of the book. In one of my first meetings with my editor Eric Chinski, he was saying that the ideal for the book is a prism: if you look at these questions from a slightly different angle, then your answers will slightly change. I wanted to find stories that would allow for that.

The book begins on a personal note. Can you talk about your decision to begin that way and to work in multiple registers throughout the book?

I knew that I had this childhood experience that on some level probably framed questions I’ve been asking since I began being a journalist. But it was when I was working on a story about children in Sweden who developed resignation syndrome, where they stopped eating and talking, that I became newly interested in my own childhood with anorexia. It felt like there were so many similarities between what I experienced and what these children were experiencing, and yet it felt wrong to compare them because our political and social situations were so different. But I became more interested in the kernel of distress that can take different forms depending on the way that families or communities or doctors respond to it. Working on that story in Sweden crystallized some of those questions and gave me a new way to think about my own experience.

The “Laura” chapter, which discusses a high-achieving person who decides to stop taking medications prescribed for borderline personality disorder, was originally published in in April 2019. You made significant changes to the magazine piece for the book—most notably, by inserting your own experience of going on and off Lexapro. Do you want to say more about your decision to include that with Laura’s story?

My feelings about Laura’s story evolved in the process of writing the book. I feel like there is this thread within psychiatry of, “I’ve been oppressed by psychiatry, and if only I free myself from psychiatry, I will be well again,” and I wanted to explore the ways in which that idea, too, can be reductive. The reason I had originally become interested in the issue was because I had such a hard time going off Lexapro. At the time that I met Laura, I wanted to explore why we don’t talk about how hard it is to get off these medications. I never have gotten off Lexapro, and I’m not in a clearly resolved place about it, but I wanted to bring that experience in as a kind of counterpoint to the idea there’s some sort of pure, unadulterated self, free of medications, and that this self is necessarily worth fighting for—through the painful experience of getting off medications.

Does that unadulterated self relate to the notion of the “baseline self”?

Yes, and I think, in my case at least, I don’t know if my baseline self is the one I want. It may not be that this self is ill. I just would maybe rather not be my baseline self, and that is complicated.

You draw on an astonishing breadth of material, including letters, medical records, emails, book manuscripts, unpublished journals. The book has some incredibly revealing quotations. In the Naomi chapter, you mention that before throwing herself and her children into the Mississippi River, she felt “terrified for her children, because she knew ‘their life would be filled with inferiority, indifference, and ridicule,” and she explained, “I did not want them to die. I just wanted them to live better.” And in the chapter on Laura, you say that her family sometimes joked that “Laura had become part of the couch. Her family learned to vacuum around her.” Sharing that kind of information could only have come from a place of deep trust. What was the process like of building that trust?

Actually, that first quote from Naomi was from her statement to investigators when they were interviewing her after she was arrested. That was one of the first things I read, and I was really struck by the way she spoke and articulated her concerns. That was one of the reasons I wanted to write about her; I saw that she could talk about both her personal reasons for doing something but also the way that culture affected her reasoning. With Laura, as with the other people I wrote about, I don’t come in saying, “I want to be part of your life for nine months.” I come in saying, “I want to have a conversation,” and we see how it goes. One conversation leads to the next—or it doesn’t—and I want to know that they feel comfortable and that I’m not imposing. The relationship can develop slowly, but it’s nice when there comes a point where they feel like I understand something about their story that other people have not and they can trust the way that I’ll treat it.

 In Naomi’s case, I think it was her sister who handed you two large garbage bags of documents, right?

Her sister handed it to me, but it was Naomi who arranged for it to happen. I had gone to Chicago to meet them. I also like to write about people who think something good will come from sharing their story. They’re not just doing it because they like me. They’re doing it because they feel they have something to contribute to a larger conversation. I thought that was the case with everyone I interviewed. Naomi was sharing her letters and journals from prison with me because there was material that showed her state of mind in prison and how hard it was for her and how she was trying to re-build a sense of community and purpose through these letters.

Do you do stay in touch with people that you’ve interviewed?

It varies a lot, but I just talked to Naomi like last week. We’ll communicate through email or text, and I’m aware of significant moments or changes in their lives. 

 What was your baseline understanding of psychosis, and has your definition of it shifted?

I don’t know if it changed while I was writing the book, but one of the seeds for the book was a piece I’d written for Harper’s Magazine about people in the earliest stages of psychosis. I started thinking a lot about how little we know about psychosis, in part because it’s so hard to communicate those kinds of states. It involves almost a different kind of consciousness. People were trying to describe things that happened to them, but when they put it into words, they felt they had missed the essence of what it was. People’s descriptions of how lonely that experience is—to be going through something so profound and not be able to talk about it or share it—that’s what made me think there is not enough writing about psychosis that, rather than looking at it as something foreign and dangerous, actually tries to understand what it feels like. 

That’s something that all your subjects share: they all left behind written records and felt, to some degree, at lexical odds with how psychiatry described their experiences. How would you define psychosis?

It’s complicated. Something worth thinking about is: What causes disability? At what point does an alteration of mood or cognitive and perceptual functioning cause you not to be able to do the things in life that you want to do, like work and have friends and relationships? My definition of mental illness is the same definition that a doctor would use, but I would be attentive to the parts of the mental illness that are actually causing the person distress. You can incorporate some aspects of mental illness into your life in a way that is not disabling. For instance, there’s this movement of people who hear voices and they have made an assessment that the voices cause them less distress than taking medications to treat those voices.

You also note, in the chapter on Bapu, that different cultures have different frameworks for explaining socially deviant or mystical behaviors.

Yeah. In some ways, though, for Bapu, it did cause her suffering because her condition alienated her from her family. But she was able to find an alternate community, when she escaped to healing temples, that made her feel a sense of belonging and validated her experiences as socially acceptable and even special. One of the things I focused on when I was revising that chapter was to not romanticize her experience as a mystic; there are different stories you can tell about that experience she had—schizophrenia is one and mystical experience is another. But it’s not as if viewing herself as a mystic was all good either. It took her away from people she loved.

I want to ask about how religious imagery figures into some of the thoughts of the people you write about. In Naomi’s case, after she was taken to jail, “she interpreted her cell number, which was 316, as a sign that she was God. The New Testament verse John 3:16 reads, ‘For God so loved the world, that he gave his only begotten son.’” In the case of Bapu, she regarded Krishna “as a surrogate husband” and sought to pursue the path of a devotional poet. Obviously, this is not to say that self-identifying as religious predisposes one to having religious delusions, but I’m curious what you make of the fact that quite a few of these characters imbue events with religious significance. Is it going too far to draw a parallel between certain states of altered consciousness and evangelical worship?

The phenomenology of psychosis has overlaps with the experience of spiritual union. There are elements of the way that consciousness changes in psychosis, like a collapse of boundary between the self and other, that can parallel a spiritual experience. But I also think that when you’re having an experience that feels outside of language—if you have the uncanny sense, for instance, that everyone is watching you—our culture has metaphors to explain that and one of them is, well, God is watching you. I also think part of it is feeling like, “I don’t know what’s happening to me, I need to find a way to explain it,” and a spiritual explanation may be the closest thing I can reach for.

Are you religious, or have you ever been religious?

I’m not religious, but I was as a child: I think, like a lot of kids, I was open to the possibility that maybe I’m a little prophet. There was this superstition combined with asceticism and the sense of proving yourself to be a very special person. But I think a lot of kids have that mixture of OCD and a sense of one’s own religious power, a combination that can lead to the belief that if I turn the lights off wrong, God might kill my mother.

When you were growing up, did psychoanalysis have a lot of purchase for you?

Yes, my mom was really into psychoanalysis, and I remember being told at some point—by someone trying to explain what had happened to me when I was six—that I had been rejecting my mother and mother represents milk, and that’s why I wasn’t eating, or something like that. That never made much sense to me, but a diluted version of psychoanalysis was a very meaningful framework for me, and it still is. In college, every literature paper I turned in would be a psychoanalytic reading, which got really repetitive. It’s just such a compelling way of seeing things, but I did also have the experience that a lot of people have where they realize that psychoanalysis is not necessarily true. For a long time I think I just assumed it was.

In one part of the book, you discuss the ideas of the Swiss psychiatrist Roland Kuhn and the “phenomenological school of psychiatry,” which I found fascinating. Basically, instead of viewing the brain as a black box that produces a set of symptoms or expressive markers like hallucinations to be treated and addressed, the approach tries to produce an almost immanent account of mental illness. Do you see yourself working in a similarly sympathetic mode, and do you think that this is something that ought to be brought back to mainstream psychopharmacology? 

Phenomenology is caught up in the act of describing like, “Let’s describe before we jump to explain,” and obviously, as a writer, the thing I do is describe. I do like knowing that there is a tradition in which describing is seen as something that has value on its own. I started thinking about phenomenology when I was writing that story for Harper’s Magazine because a woman that I wrote about, whom I call “Anna,” felt like her experience wasn’t well-described. I think that mapping out what the experiences are is an important step and we don’t dwell in that stage for long enough.

Do you think that one reason why mainstream psychiatry has moved away from that approach can be chalked up to the influence of drug companies and how their money often shapes the kinds of questions that are asked in pharmacological studies?

Yes. Also, the approach just takes time. It can be really validating to sit down and say, “Okay, when I have a delusion, this is what is happening.” But our health-care infrastructure does not support that. Psychiatrists are reimbursed in a way that encourages brief visits with people in which they leave with diagnosis and medication and are on their way.

This is more of a meta point, but I also found that section so interesting because you give a sense of how the “career” of psychiatry itself could have gone another way. In an earlier part, you write, “There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.” The line seemed not only to apply to individuals who exist at the fraying edges of reality, but could also apply to the discipline of psychiatry, at least as we know it today.

I’m so glad you felt that way because I did want that sentence to echo the earlier one, but assumed it would go unnoticed. Thank you for noticing. What has always been so interesting to me about psychiatry is how there are these master narratives that have really shaped the field. Ray’s story embodied these two master narratives, but his story wasn’t fully explained by either of them. He was really complicated, and it was complicated for me, too, because he wasn’t just sick, he was also unlikeable to a lot of people, which clouded the view.

The “Naomi” chapter also sheds light on the overlap of psychiatric illness and the criminal-legal system. It makes me think of the Penrose Hypothesis, named after a British doctor who predicted in the 1930s that as the number of beds available for in-patient psychiatric treatment declined, the number of people in prison would rise at a similar rate. That inverse relationship seems to hold true when you look at the situation in the US, where a mentally ill person is more likely to be treated in jail than in a hospital, and corrections officers almost serve as de facto clinicians. By some estimates, more than half of the prisoners incarcerated in the US have some kind of mental illness, and something like 75 percent of incarcerated women are mentally ill. What are your thoughts on the intersection of the two?

You’ve just stated them very well. It’s so sad that there was such idealism in the ’60s, i.e., the idea that we will close the asylums and we will treat people in the community. There was a sense of promise and good intentions, but that dream quickly collapsed and got deprioritized and later subsumed into this other goal of being “tough on crime.” There have been moments of wanting to fix the problem, but it never seems to last. 

It’s hard to read that chapter and not conclude that most mentally ill people in prison belong not in prison but in hospitals with proper mental-health providers. It also makes me think of how the scholar Alondra Nelson has said (riffing on Latour) that “health is politics by other means.” Do you think it makes sense to view the incarceration of the mentally ill through a civil rights lens?

If you have a mental illness, what is more terrifying, what is going to exacerbate it more, than spending almost all your hours alone in a cell or interacting with people who genuinely have fears of being attacked or injured? Every sort of fear you would have because of a mental illness is intensified in the setting of prison. You don’t even need to be an abolitionist to see how medically inappropriate that is. The bar is so high for seeing someone as not mentally competent, and even if someone is deemed not competent, they often end up in a place that can be just as bad as prison, like a psychiatric hospital, but it’s state-ordered. It just seems either scenario is likely to exacerbate the problem that contributed to whatever crime occurred in the first place.

In an interview with Nieman News, you talked about how fiction feeds into your work and inspires some of your best questions to your interview subjects. In the book itself, you interleave quotes from novels by Toni Morrison and Walker Percy and poems by Jane Kenyon. What kinds of books were you reading while writing these chapters?

It changed for each chapter. When I was writing Naomi’s chapter, I wanted to read anything that touched on mental health or grief among Black families, because there wasn’t much written about it from a scholarly perspective. A novelist touched on this sense of how melancholy has been this perennial core of a lot of literature about Black families. Elyn Saks’s The Center Cannot Hold: My Journey Through Madness opened up the idea of psychosis for me, as did Louis A. Sass’s Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought, which looks at Modernist literature and how some of the ideas that are expressed there, like alienation and the sense of self consciousness, resembles the experience of being schizophrenic. He’s a clinical psychologist, and just wants to understand the cognitive, perceptual experience, and because there’s not very good psychiatric writing, he looks to literature to find those descriptions.

One last question: What is the most popular misconception that people might have about psychosis? 

That someone who’s psychotic is dangerous. Psychosis is a very specific state of mind that doesn’t have a connection to danger the way that it often does in the popular imagination. 

Rhoda Feng is a freelance writer whose writing has appeared in the New RepublicJacobin, the White Review, 4Columns, BOMB, and elsewhere.