Rachel Aviv was hospitalized for “failure to eat” when she was 6 years old. The doctors at Children’s Hospital of Michigan diagnosed her with anorexia and attributed the problem to tension between her recently divorced parents. Six weeks later, she was eating, and the hospital discharged her to first grade.

The experience left Aviv, a staff writer at the New Yorker, with an enduring interest in how mental illness shapes self-understanding. She became captivated, in particular, by the early phases of mental illness, when the condition is “consuming and disabling but has not yet remade a person’s identity and social world.”

Review

Farrar

“Strangers to Ourselves: Unsettled Minds and the Stories That Make Us”

By Rachel Aviv

Farrar, Straus and Giroux. 288 pages.

$28.

It is those early phases that Aviv depicts in “Strangers to Ourselves: Unsettled Minds and the Stories That Make Us.” Each of four chapters, prologue and epilogue is devoted to a person with mental illness, including the author herself when she was young. The accounts are vivid, wrenching and ambitiously researched and include dispatches from the subjects’ voluminous diaries, blogs and unpublished memoirs.

Among her subjects is Ray Osheroff, a man with severe depression who was caught between the psychoanalytic and biochemical explanations of his condition. In 1979, the hard-charging nephrologist admitted himself to Chestnut Lodge, an elite psychiatric hospital outside Washington where the psychoanalytic model of diagnosis and treatment reigned supreme.

His analyst at the Lodge construed Osheroff’s relentless agitation, obsessive rumination and crushing despair as manifestations of narcissism that needed to be treated by restructuring his personality. “There had to be some tearing down and rebuilding,” in the words of a social worker there. For eight tormented months, doctors refused his requests for medication, so he moved to a medication-friendly facility in Connecticut. Within a month, his most severe symptoms resolved.

Osheroff sued Chestnut Lodge for malpractice in 1982 and settled. According to the New York Times, the case shook “the conventional belief, held even by some doctors, that chronic depression is not an illness, but merely a character flaw.” Later in life, Osheroff no longer saw his depressive ordeal as an illness – a designation that had once brought him great relief – but as “a state of disconnection.” Aviv concludes that “two different stories about his illness, the psychoanalytic and the neurobiological, had failed him.”

Naomi Gaines, a young Black woman from Minneapolis, was distressed by the racial injustice she saw around her. In 2003, while in the grip of postpartum psychosis, she threw her 1-year-old twin boys off the Wabasha Street Bridge, then jumped after them into the water below. Gaines and one son survived. Her psychiatrists understood her suicide attempt as “a choice she made in order to act out her defiance to society which she perceived as ‘oppressive and unjust.’ ” They could not accept that her existential concerns influenced the content of her psychotic symptoms. In short, the psychiatrists confused her mental illness with her ideology.

Laura Delano was from an elite Greenwich, Connecticut, family. While at Harvard, she was diagnosed as having bipolar II disorder. “It was like being told: It’s not your fault,” she said. “You are not lazy. You are not irresponsible.” When another psychiatrist changed Delano’s diagnosis to borderline personality disorder – a fuzzier diagnosis and one mainly given to women – she felt betrayed. “The story that was supposed to explain her life wasn’t offering the kind of clarity or healing she felt she’d been promised,” Aviv writes.

Eventually, Delano decided to discontinue her medications (doing so was a slow, complicated process). “I never had a baseline sense of myself, of who I am, of what my capacities are,” she explained. Once medication-free, Delano felt somewhat better but said she was “still wondering how to be an adult in this world.” Much of her time these days is spent coaching others through the medication withdrawal process.

As for the author herself, she says she was “recruited” for anorexia, but the illness never became a ” ‘career.’ It didn’t provide the language with which I came to understand myself.” Instead, she regarded her childhood eating disorder as a way of coping with stress.

Aviv wonders why her story saved her from a “career” of mental illness but others’ stories were less salutary. The answer, she speculates, “requires paying more attention to the distance between the psychiatric models that explain illness and the stories through which people find meaning themselves.”

True enough. And no one would agree more than psychiatrists. Before the Osheroff case, Chestnut Lodge was the site of lectures by Harry Stack Sullivan, an influential American psychiatrist who recommended more or less the approach that Aviv seems to favor, focusing on the particulars of a patient’s early and recent life, including issues like social class and ethnicity.

Thirty years ago, psychiatrist Peter Kramer, the author of “Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self,” (whom Aviv interviews) was perhaps the first to examine the relationship between medication and identity.

In a perfect illustration of such remaking, Aviv describes how her antidepressant affected her desire for children. She stopped the medication when she became pregnant but soon felt estranged from prospective motherhood. Upon restarting the drug, she was “connected again to my reasons for having a baby.”

These days, health-care systems often relegate psychiatrists to prescribing and little else. Even so, psychiatrists recognize that patients form bonds with their diagnoses, for better or worse. Like their patients, they also puzzle over the mystery of where drug effects leave off and the “true” self begins. One of the goals of psychotherapy, in fact, is to help patients fashion a narrative that, ideally, brings them insight and freedom – just as the author prescribes.

The book is organized around a profound and plausible hypothesis: that the stories people tell themselves about their mental disorders shape the course of their lives. Yet the case studies in this book cannot prove it, as the author seems to suggest.

After all, Aviv might have had the same brilliant future no matter what she told herself about her eating disorder. Her subjects – who still face considerable challenges in life – may have fared worse than Aviv not because they could not construct a better storyline for themselves but because they were inherently sicker.

This year, Aviv won a National Magazine Award for profile writing. “Strangers to Ourselves” showcases her mastery of psychological portraiture. It is these stories and the ones her subjects tell themselves about their mental disorders that fascinate. As for the author’s framing questions, while they are essential to ask, they remain unanswered.

Sally Satel is a forensic psychiatry fellow at St. Elizabeths Hospital and a senior fellow at the American Enterprise Institute.