Daniel's Staff Pick: October 20, 2022

Rachel Aviv: Strangers to Ourselves: Unsettled Minds and the Stories That Make Us book (2022, Farrar, Straus and Giroux)

Apologies to the punk fiends this week, because my staff pick has nothing to do with punk rock. However, I always tell SSR’s staffers they can write about what they want, and my process for choosing a staff pick is usually just to take a moment to reflect on what moved me during the past week and go from there. Strangers to Ourselves is the best book I’ve read in a while, so I thought I’d share. Plus, I know there are a handful of folks out there with interests in both punk and psychology (like Angela here at Sorry State and Red who sings for my band Scarecrow), so maybe some people will learn about this book here and enjoy it. Or maybe I’m just writing to the void. That’s OK too.

I don’t have a background in academic psychology, but I kept coming across glowing reviews of Strangers to Ourselves in publications I trust like The Atlantic and The New York Times. I’ve also been craving human stories in my reading… I want to know about people, to hear their stories and their wisdom, and the case study format of this book seemed like a good fit for what I’ve been looking for. Further, I have my own experiences with mental illness and the world of mental health treatment, so I have some connection with the book’s topic. I gave it a try and downloaded the ebook, which I found difficult to put down once I’d started.

Strangers to Ourselves is centered on four cases studies that detail their subjects’ encounters with the mental health industrial complex. Right off the bat, this approach puts Aviv at odds with the direction psychology has been headed over the past several decades. Throughout the first three-quarters of the twentieth century, psychology was steeped in Freud’s thought, viewing mental health as highly individual, and treatment for mental health disorders involved understanding an individual’s experience through a painstaking process of one-on-one psychoanalysis. This approach fell out of favor in the latter decades of the 20th century as a new generation of psychologists attempted to bring the rigor of the natural sciences to their discipline. This change in approach gave birth to the idea of randomized clinical trials, the Diagnostic and Statistical Manual of Mental Disorders, and (most significantly for patients) the embrace of pharmacology, or treating mental disorders with drugs. These changes were not only significant to the working lives of psychologists and psychiatrists, they upended and changed the ways our culture thinks of mental health and the kinds of treatments people receive when they experience mental health challenges and crises.

While the case study approach has fallen out of favor as an academic tool, it makes for great reading as Aviv delves into her four subjects’ stories (as well as her own story of being (mis-?) diagnosed with anorexia as a very young child). Her subjects’ stories are rich, exhibiting the complexity and mutability of human experience. They are genuinely touching, and at its core that’s why I couldn’t put the book down.

The idea of “insight” is key to each of the four case studies, and the idea gives the book its narrative arc. On the surface, “insight” refers to a patient’s understanding of their own condition. However, we see the way psychologists understand their patients’ conditions undergo an almost total 180 over the course of the book, which calls into question the entire premise of “insight.” The book’s first case study illustrates this most clearly. The subject is a depressed middle-aged man, a successful business owner whose condition doesn’t seem warranted by his material circumstances. The place he seeks treatment (this is all happening in the late 70s) is one of the last remaining holdovers of the older, Freudian approach to psychology. The therapists there basically tell the guy to get over it, and he doesn’t respond well to this treatment. The doctors note that he doesn’t have insight into his condition. When he later seeks treatment at a more modern facility and starts including pharmaceuticals as part of his treatment plan, he makes immediate and substantial progress.

The next two case studies are interesting because their subjects exhibit a kind of insight, but not the type of insight that psychologists value or expect to see. A woman in India experiences a religious awakening that her family processes as a mental health crisis, and the conflict between those two ways of seeing her experience has a profound impact on the lives of everyone in the family. The woman has a kind of insight—in fact, the people around her view her as a literal saint later in life, once she and her family find some measure of peace and stability—but that insight has nothing to do with our models of good mental health. It’s easy to see how history’s most prominent religious figures would have been viewed as psychotics by today’s rubrics. The third case study looks at a black woman who experiences what I’d call delusions, but she has profound insight into how race frames the way psychologists and the justice system see her. Of course, this isn’t the type of insight those parties are looking for, but I’m thankful Aviv’s approach allows us to benefit from it.

The last case study was particularly interesting to me because I saw so much of myself in it. This study follows a high-achieving young woman whose life is ripped apart when she receives treatment while a student at Harvard. She is very smart, and adept at showing the type of insight her caregivers are looking for. When a doctor diagnoses her with a condition, she adopts that diagnosis as gospel truth and sees herself through that diagnostic lens. And because she appears to fit diagnostic criteria so well, she is prescribed a litany of drugs to manage her lifestyle and keep her meeting those high expectations. She is the mirror image of the first case study, whose subject just needed someone to diagnose him with depression and give him a now-standard treatment for it. Instead, it seems like what this patient needs is for people to stop doling out drugs and to see her as a complete human being rather than a bundle of diagnostic criteria.

In the last part of the book, Aviv goes into detail about her own experience with the drug Lexapro, which I also take. This part of the book hit close to home, and it deftly exhibits how the changes in psychology that upended her subjects’ lives has also had profound, if less extreme, effects on all of us who have sought and/or received mental health treatment. I worry I’ve given too much away, but if you’ve also had experience with the world of mental health care, Strangers to Ourselves may provide you with some valuable insight. It’s certainly done that for me.