Rachel Aviv opens her fascinating study of mental illness and narrative with her own story of being hospitalized with anorexia at the age of 6. One of the youngest patients to be diagnosed with the illness, she relates that she “was ‘recruited’ for anorexia, but the illness never became a ‘career.’” While she recovered from her eating disorder, many patients — including her friend Hava — struggle with the malady their entire lives.

“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,’” Aviv writes. “Answering the question, I think, requires paying more attention to the distance between the psychiatric models that explain illness and the stories through which people find meaning themselves.”

Aviv’s central project in Strangers to Ourselves is to explore narratives of mental illness — both the ones told to patients (in the form of diagnoses) and the ones patients tell themselves — in an effort to probe “the psychic hinterlands, the outer edges of human experience, where language tends to fail.” These are stories of people who 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.” Her project attempts to capture “missing stories, the facets of identity that our theories of the mind fail to capture.”

What follows is a series of case studies of individuals who have found themselves in these “psychic hinterlands.” The first examines Ray Osheroff, a successful doctor who sought treatment for depression in the late 1970s at Chestnut Lodge, a Maryland facility that specialized in psychoanalysis. After failing to improve and moving to another facility, where he was prescribed antidepressants, Osheroff sued Chestnut Lodge for not adequately treating his depression. “In the lawsuit,” Aviv writes, “the twentieth century’s two dominant explanations for mental distress collided.”

Chestnut Lodge eventually settled, but the field of psychiatry was changed forever. Not only did Chestnut Lodge begin prescribing medication — in order to avoid future lawsuits — but the involved, expensive process of psychoanalysis was pushed out of the mainstream when insurance companies moved to managed care in the early 1990s. “Long, elegant narratives of patients’ struggles were replaced by checklists of symptoms,” Aviv writes. “Mental-health care had to be treated as a commodity, rather than a collaboration.”

And yet in the end, despite taking psychiatric medication for three decades, Osheroff “felt rootless and alone.” Aviv explains: “Two different stories about his illness, the psychoanalytic and neurobiological, had failed him. Now he was hopeful that he would be saved by a new story, the memoir he was writing.” He worked for years on the book, which ballooned to 500 pages, yet never finished it, sensing “that any story that resolved his problems too completely was untrue, an evasion of the unknown.”

The next chapter focuses on Bapu, a woman in India whose extreme religious practices and dedication to the Hindu god Krishna in the 1960s led her to be diagnosed with schizophrenia. “She understood her devotion through a story that was celebrated by fellow worshippers and by the literature she read, and, when it was forcibly replaced by a new one about mental illness, she felt devalued,” Aviv writes.

While her doctor (who was trained in the Western tradition) reports that Bapu “was one of the worst cases of schizophrenia” he had ever seen and assumed she had no insight into her own condition, Aviv points out that “Bapu was not treated as a credible witness to her own experience, not only because of her status as a patient but also because of colonial notions about the irrationality of Indian religions.”

Like Ray Osheroff, Bapu left behind numerous writings — her own reckoning of her experience — and her legacy continues in the Bapu Trust, a nonprofit started by her daughter to help families like theirs address mental illness “in ways that were reflective of their own experiences, rather than using language that seemed to have been designed for a different model of the self.”

In the next study, Aviv explores the case of Naomi Gaines, a Black mother of four in Saint Paul, Minnesota, who, in 2003, threw her 1-year-old twins off a bridge and then jumped in the water herself. Suffering under delusions, she was convinced that she and her family were going to be murdered, so she decided to pick “a merciful death” over a “torturous one.” Gaines and one of her sons were rescued by a bystander, but the other boy died. Aviv traces the course of Gaines’ life that led to the disastrous moment on the bridge.

“Mental-health institutions were not designed to address the kind of ailments that arise from being marginalized or oppressed for generations,” she writes, noting that “one of this country’s founding myths is that Black people don’t go crazy.” While serving a sentence for second-degree murder, Gaines began to write a memoir to share her experience with others. “I have survived the darker aspects of myself,” she wrote. “What I’ve done and where I’ve been is not who I am.”   

While Naomi Gaines suffered from a lack of mental-health resources, Laura Delano, a privileged young white woman, had the opposite problem. The debutante and Harvard student struggled to feel a “real self underneath” all of her achievements and the expectations placed upon her, which led her to seek medical treatment for what was initially diagnosed as bipolar disorder.

“The psychiatrist told me who I was in a way that felt more concrete than I’d ever conceptualized before,” Delano explained. Because “her psychiatrists seemed to feel a duty to preserve her capacity to function at the highest levels, almost treating subpar performance as a symptom of its own,” Delano eventually experienced a “prescription cascade,” taking 19 different medications in 14 years.

After forming a self-image based on her bipolar disorder, she felt like her identity had been stripped from her when another doctor told her she instead had borderline personality disorder. “I never had a baseline sense of myself, of who I am, of what my capacities are,” Delano said. “Mental health has become synonymous with the absence of symptoms,” Aviv explains, “rather than a return to a personal baseline, her mood and personality before and between periods of crisis.”

In order to discover and reclaim this “baseline self,” Delano made the decision to stop taking all her psychiatric medications; she has since become a leader in the online community of people struggling to go off meds. While Delano realizes that a psychiatrist would still find that she meets “the criteria for a number of diagnoses,” the “diagnostic framework” no longer feels meaningful to her. She has found her story elsewhere.

In crafting compassionate, probing portraits of people who have forged their own stories, Rachel Aviv has written an engrossing and important book that shows how managed care and the current state of mental-health treatment is working from a two-dimensional model that reduces patients to diagnoses and — in some cases — dooms them to “careers” in mental illness that they cannot escape. With Strangers to Ourselves, she reminds us that we are all more complex, more multi-dimensional, more fascinating and mysterious than any single diagnosis, and that the real stories of who we are are worth probing in depth.

Yelizaveta P. Renfro is the author of a book of nonfiction, Xylotheque: Essays, and a collection of short stories, A Catalogue of Everything in the World. Her fiction and nonfiction have appeared in Glimmer Train Stories, Creative Nonfiction, North American Review, Colorado Review, Alaska Quarterly Review, South Dakota Review, Witness, Reader's Digest, and elsewhere. She holds an MFA from George Mason University and a Ph.D. from the University of Nebraska.

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