What Do We Really Know About Mental Illness?

When Rachel Aviv was six years old, she stopped eating. Shortly after, she was hospitalized with anorexia. Her doctors were flummoxed. They’d never seen a child so young develop the eating disorder, yet there she was. Was it a response to her parents’ divorce? Diet culture? Innate asceticism? The episode remained mysterious. While Aviv made a full, relatively speedy recovery, she developed a lifelong interest in the borderlands between sickness and health.

In her new book, Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, Aviv wonders whether she ever truly had anorexia at all, or whether the episode was perhaps too hastily pathologized. While she moved on from her bout of disordered eating without seeing it as a fixed part of herself, the girls she lived with in treatment—older, more self-aware—did not shake it off. Instead, their identities were subsumed by the anorexia. “Mental illnesses are often seen as chronic and intractable forces that take over our lives, but I wonder how much the stories we tell about them, especially at the beginning, shape their course,” Aviv writes. “People can feel freed by these stories, but they can also get stuck in them.”

If anyone knows the weight of stories, Aviv does. She’s a star New Yorker writer, capable of drilling into complicated, morally queasy situations and excavating definitive tales from the chaos. (Read her work on child welfare system overreach, please.) But Strangers to Ourselves is doggedly resistant to sounding definitive. Instead, it is insistent on ambivalence. The book is divided into four chapters, each one focusing on a different person with unusual mental health issues. (A prologue and epilogue delve into Aviv’s personal experiences.) These characters include Ray, a dermatologist who sues a ritzy mental institution for not giving him antidepressants; a Hindu mystic named Bapu, whose family has her institutionalized for schizophrenia; and a single mom named Naomi, incarcerated after she jumped off a bridge with her two sons in a suicide attempt, killing one. Their circumstances and conditions have little in common except extremity and uncertainty about what is really happening to them.

Aviv’s thesis is that there can be no grand unifying theory of the mind. “The theory of the chemical imbalance, which had become widespread by the nineties, has survived for so long perhaps because the reality—that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors—is more difficult to conceptualize, so nothing has taken its place,” she writes. Strangers to Ourselves is a look into this vacuum of understanding—about what happens when there’s no easily digestible story to explain what’s happening inside your head, when Freud and pharmaceuticals and everything else fails.

A later chapter, “Laura,” functions as an elegant but inconclusive interrogation of contemporary psychiatry. Connecticut blue blood Laura Delano was diagnosed with bipolar disorder early in life, and started her first psychiatric medication at the same time. She was a high achiever, attending Harvard, but she continued to struggle with her mental health; by her early twenties, she was heavily medicated and had survived a suicide attempt when she stumbled upon a book critical of psychiatric drugs. She decided to stop taking hers. Despite serious withdrawal symptoms as she weaned herself off pills, she preferred her life unmedicated. She became active in anti-psychiatric drug circles on the internet, eventually starting a popular blog. Aviv reveals that she found Laura’s writing while she was trying to understand her own relationship to psychopharmaceuticals—she has taken Lexapro for many years, and had wondered whether she might stop. Aviv does not go so far as to embrace the anti-psychiatry movement herself, although she treats Laura’s position with respect. She makes peace with her continued reliance on antianxiety medication for mental equilibrium, even as she ponders how little doctors know about why exactly it works. But she worries about how diagnoses can limit people’s understanding of themselves and what is possible.

In this regard, Strangers to Ourselves is an of-the-moment book. This summer, a paper reviewing the available literature on the link between depression and a serotonin imbalance concluded that there is no evident link. “The chemical imbalance theory of depression is dead,” The Guardian declared. Renewed skepticism of the biological model for understanding a wide variety of mental illnesses is rising. So Aviv’s persuasive writing on the necessity of considering the whole person, rather than their brain chemistry alone, is apt, albeit not particularly novel. Strangers to Ourselves joins a growing body of recent nonfiction complicating our understanding of the mind. In 2019, medical historian Ann Harrington published Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, a frequently eye-popping tour of psychiatry as it shifted from the Freudian to the biological model, underscoring how fraught chemical imbalance theory has always been. Neurologist Suzanne O’Sullivan’s 2021 book The Sleeping Beauties: And Other Stories of Mystery Illness delved into culture-bound syndromes and psychogenic illnesses, illustrating how intensely our environments and experiences can impact the ways our bodies and minds function. The strength of Strangers to Ourselves is in its engrossing case studies, which contribute vivid anecdotes to this ongoing conversation about the complex and perplexing nature of the mind.

Early on Aviv explains that she chose an episodic structure for the book, rather than one overarching narrative, in order to emphasize the sheer variety of emotional and psychic experiences, their fundamental irreducibility, their need for specific contextualization. Only a series of narratives could illustrate the point that there is no one singularly true narrative. “When questions are examined from different angles, the answers continually change,” she writes. This sentence is both undeniably true and maddeningly equivocal, like somebody saying “all music is good … depending on a person’s taste.” Sure, but so what? Taken individually, each story in Strangers to Ourselves is as typically excellent as Aviv’s magazine journalism, viscerally rendered and thoughtful portraits that slide into meditations on the mind. As a collection, though, they coalesce into an eloquent shrug. I wondered, upon closing the book, whether it might have left a firmer impression had it been published in serialized form—say, in a magazine—rather than gathered into a collection so opposed to clarity.

Better a sincere, beautifully written whimper than a disingenuous bang, of course. Aviv’s hazy but honest irresolution is much preferable to the blunt-force tendency to turn mental health diagnoses into cornerstones of identity, fixed personality traits rather than the often slippery, provisional snapshots of a person in one moment that they often are.