Traveling the Psychic Hinterlands

Traveling the Psychic Hinterlands

A conversation with Rachel Aviv, the author of Strangers to Ourselves: Unsettled Minds and the Stories That Make Us.

Booked is a series of interviews about new books. For this edition, Dissent associate editor Lyra Walsh Fuchs talks to Rachel Aviv, the author of Strangers to Ourselves: Unsettled Minds and the Stories That Make Us (FSG).

Strangers to Ourselves opens with Rachel Aviv recounting her own institutionalization at the age of six, when she suddenly refused to eat. She was completely unaware of the term “anorexia” before her doctors—and the sisterly teenagers on her floor—spoke it aloud. By then, she avoided even saying the names of foods because it felt like consuming them.

Driven by the promise that if she ate her meals she would be allowed visits from her parents, Aviv eventually recovered and returned to elementary school. While she fared better than some of the girls she got to know in the hospital, the experience—her visit to what she calls the “psychic hinterlands”—stayed with her, as did her sense of the power of names and diagnoses. “It’s startling to realize how narrowly we avoid, or miss, living radically different lives,” she writes at the close of the chapter.

Aviv is now a staff writer at the New Yorker, and in her first book, she profiles five people wrestling with their mental health and their various treatments and diagnoses. An empathetic and deeply researched book, it is at once timely—50 million Americans are currently experiencing mental illness, according to one conservative estimate—and part of a long tradition of texts attempting to understand the mind. In this conversation, which has been edited for length and clarity, we spoke about healthcare, motherhood, anti-psychiatry, and more.

Lyra Walsh Fuchs: Strangers to Ourselves is not an explicitly political book, but there is, certainly, a politics in its insistence that peoples’ minds are shaped by the environments that they develop in—and also that every person deserves dignity. How would you describe the politics of the book?

Rachel Aviv: Mental health is a space that doesn’t align with one particular political school of thought. But there’s something wrong with a society that funnels so many people who are mentally ill into the prison system, and then goes one step further and takes some of the most mentally ill people in the prison and funnels them into solitary confinement.

And it’s worth noting that it might feel very different for a white, upper-middle-class person to be told that their mental illness is biological than for people who have struggled with poverty or discrimination all their lives. Their response to this explanation might be, “You’re ignoring the way that all of these things have pushed me to a point of crisis.”

Walsh Fuchs: To that point, you write about how some people find meaning in a diagnosis, and how for others—or maybe even the same people at different times—a diagnosis becoming “a defining fact” of their lives ends up being harmful. What do you think about the way that the healthcare and welfare systems demand diagnoses?

Aviv: Diagnoses are necessary: we need them to communicate. They serve a purpose that is non-negotiable. But the dictates of managed care endow diagnoses with disproportionate importance. In order to be reimbursed for care, doctors need to give a diagnosis, often after just meeting the patient. I do wonder if, once the diagnosis is given, there is a failure to recognize how subjective and provisional it is, and it may discourage curiosity, both on the part of the patient and the doctor, in terms of seeking suitable, individual answers to what is really going on.

The role that diagnoses play feels even more disproportionate when it comes to disability benefits: people can get locked in a kind of “illness career” because they need that diagnosis to get support from the government. The scholar Helena Hansen describes this as the “pathologization of poverty”: when the government cut back on welfare benefits in the late nineties, medical claims became the new avenue to qualify for government benefits—there were suddenly bureaucratic pressures to qualify for a psychiatric diagnosis in order to financially survive.

Walsh Fuchs: Are there any solutions to that problem?

Aviv: There’s been a lot more advocacy among patients—most prominently perhaps the Hearing Voices Movement—who have argued that experts should pay more attention to what the patient is saying about what is causing them distress. People in the Hearing Voices Movement will argue that sometimes the side effects of medications are more disabling than the voices, and, if a patient can learn to live with voices, they should be allowed and even encouraged to make that choice. They will argue that there is a wide spectrum of voice-hearing experiences, and, if hearing voices is not getting in the way of the person living a fulfilling life, they don’t necessarily need to be treated or deemed pathological.

Walsh Fuchs: The majority of the book’s subjects are mothers. Mothers have always played an outsize role in the development of psychology and psychoanalysis. In your book, the doctors at the Lodge, a residential treatment facility, are described as “substitute mothers.” Was it a coincidence that you ended up writing about so many mothers?

Aviv: I think it largely was. But it was also a way to express how mental illness spills over from one generation to the next. There are so many ethical questions about what it means to be a mother who has a mental illness, how it affects the child, whether you are doing something selfish by having a child, and how the child responds to seeing a parent who is mentally ill. I also am a mother of young children, so maybe I was more attentive to the pain of wanting the best for your child and worrying that you can’t achieve that for many reasons, some of which involve the way your brain works.

The chapter about Naomi focuses specifically on Black mothers, a population that psychiatry has not served well, in part because Black mothers have been seen as playing this role of carrying everyone’s burden. They are not often given the option of being depressed. Alternatively, there’s a long tradition of white mothers being the ideal target of psychiatry: these figures who are fraying under the pressure of trying to “have it all”: competence as a mother and wife, and a professional career, too.

Walsh Fuchs: “Mommy’s little helper.”

Aviv: Yes, I found that parallel really striking. There’s the white mother who can take medications to have it all, and the Black mother whose suffering is not taken seriously from a medical perspective because, according to the stereotype, she’s facing so many genuine obstacles in her life that there’s no need to look at biology.

Walsh Fuchs: In your book, you write about how the court said that Naomi was paranoid because she was afraid of being gassed—but she had in fact been gassed while she was incarcerated. That example was so striking. Do you have a sense of whether she is currently finding it useful to understand her experience as postpartum psychosis?

Aviv: Yeah, she does find it useful. Seeing it in medical terms was especially useful because she had such incredible guilt about what she had done to her children when she was psychotic, and what do you do with that guilt? Understanding it as a disease helped with surviving that guilt.

Walsh Fuchs: Did that help her to continue to do the sort of political thinking she wanted to do?

Aviv: Well, in a way, taking medications allowed her mind to be clearer, to become more open to other interpretations. She began reading literature and discovering a tradition of Black mothers struggling through the kinds of experiences she’d had.

Walsh Fuchs: There seems to be a rise of anti-psychiatry right now. Writers like P.E. Moskowitz are sounding the alarm about overdependence on psychiatric drugs, withdrawal, and overidentification with diagnoses. How do you see your book relating to this anti-psychiatry tendency?

Aviv: It’s unequivocable that there’s over-prescription and that psychiatric medication is too often used as the only solution. But there’s a way in which anti-psychiatry can be reductive and diminish the real disability that people experience. I don’t know why it has to be an either/or: that it’s either within the person, or her society—it is also about the relationship between the person and the society. People do have really damaging experiences on medication, but people are also living lives that wouldn’t be possible without medication. I think both truths have to be acknowledged at the same time.

Walsh Fuchs: It strikes me that a lot of the criticism is about a lack of education about how to taper off medication. You’ve written about your own experience with that. That’s something I have also struggled with.

Aviv: After writing that piece in the New Yorker [about withdrawal from psychiatric medications], I worried that my story was going to make people go off their medications, which I did not want. But then I was also aware that the fear of this is part of why there has been so little public discussion about withdrawal, because doctors and policy leaders are scared of people not taking medications when they need them. That’s its own kind of paternalism—to not give people the full scope of information, because you fear that they won’t handle it properly.

Walsh Fuchs: Do you have a sense of any clinicians or researchers who are coming up with a helpful way to talk about this?

Aviv: There’s a psychiatrist named Giovanni Fava who has done a lot of work on antidepressant withdrawal. He’s the only person that I know of who has dedicated his career to studying this issue, because he felt like this was a phenomenon that wasn’t really being acknowledged, and too often it was being misread and misclassified.

Walsh Fuchs: I don’t know if you’re on TikTok, but there is a fair amount of self-diagnosis and videos where people say, “You might have dissociative identity disorder if you zone out.” Some of it describes what seems to be common human experiences that, while unpleasant, aren’t necessarily cause for concern. But these videos are resonating with thousands of people.

Aviv: I have always been interested in the historical moment when multiple personality disorder proliferated. It was a certain kind of woman in a certain era in a certain moment in American history, and almost nowhere else in the world. It makes a lot of sense to say that it’s good to talk about mental health to destigmatize it. But then what if talking about it reifies the idea of the illness, and makes people identify as sick in a way that limits them? Because it does seem like mental illness, regardless of the diagnosis, often coincides with a sense of suggestibility: losing one’s sense of confidence; losing a sense of boundaries—these things can make people more dependent on what others say and how they see you.

Walsh Fuchs: If we’re thinking about the left in particular, on the one hand there’s a commendable consciousness of centering peoples’ disabilities, and then on the other there’s people who say, “Well, of course you’re depressed; it sucks to live under capitalism.” Or, “You’re not depressed, you’re just a capitalist subject.” 

Aviv: Now it does feel nostalgic to remember that in the 1970s and ’80s, when people came in to see a doctor, and the doctor could just assume that their mental struggle was the fault of their family. Were things really that good then? To pretend that it’s not related to the world outside the family doesn’t make sense anymore.

Lyra Walsh Fuchs is Dissent’s associate editor.

Rachel Aviv is a staff writer at the New Yorker and the author of Strangers to Ourselves: Unsettled Minds and the Stories That Make Us.