Abstract
Roy Porter described the past as being like the night sky: billions and billions of stars, but mostly darkness. If only we were so fortunate with mental illness where we have hardly any stars at all – enough to discover Orion’s belt, but not Orion. Yet our ignorance offers no impediment to our imagination, whose hunger is exceeded only by our therapeutic ambition, compelling us not only to tell stories to make sense of the senseless but also to intervene based on those tellings, and often, as Professor Andrew Scull recently reminded us, to the detriment (or worse) of those whose suffering we had hoped to relieve.
Much as I admire Scull’s work, I would hardly gainsay that psychiatry has made a difference – for the better – in the lives of millions, including my own. What disturbs me is not the practice but the pretence. What New Yorker writer Rachel Aviv suggests in her brilliant new work, Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, is this: that something is amiss with psychiatry’s ‘stories that make us’, be it a nosology bereft of biological or genomic correlates, or metaphors, like Oedipus complex and chemical imbalance, that are no less dubious.
The author introduces us to six embodied souls (including her own) seeking to make sense of themselves, their circumstances, and the time they had spent under the care of purported experts claiming to understand and calm their ‘unsettled minds’, through hospitalization, psychoanalysis/psychotherapy, psychopharmacology, or some combination thereof.
Because her book has been reviewed widely, my focus will be more on form than content. Each of Rachel Aviv’s stories stands on its own, though on occasion there are cross references. Taken together they comprise a rich tapestry, spanning time and place, race and ethnicity, and gender. What distinguishes these tellings from virtually every psychiatric case study I have read is the extraordinary sources she uses to tell them. These include not only personal accounts (e.g. diaries, journals and memoirs) but also hitherto unseen medical records, legal documents, video, and intrepid reporting, plus interviews with many of her subjects, their friends, family and physicians.
A surprising absence, however, is the inclusion of any of the documents she cites in her extensive notes within the body of the text itself – in, say, an analogous fashion to what Susanna Kaysen (1994) did in Girl Interrupted. That said, Ms Aviv compensates for this absence by writing closely to her sources. Doing so is both a strength and a weakness: a strength because it constrains her from taking unreasonable flights of fancy, and a weakness because it impedes her, at least in my opinion, from generating insights beyond the time-worn inferences she draws from her sources. I do not mean to suggest that the author’s assertions are off target; on the contrary, many are spot on. But none, I think, hits the bullseye because that is a difficult thing to do.
In each of her stories, she casts her trenchant gaze on how psychiatric diagnoses – what she calls the profession’s ‘stories’ – become manifest in the lives of human beings. Some derive comfort from these stories; others find themselves in peril because of them. That such an accomplished storyteller would herself attribute causal significance to them is hardly a surprise. But is she right? Do stories ‘make us’? Or, more particularly, do stories of illness? Would any of the people about whom Ms Aviv writes have fared better (or worse) had different stories been associated with their diagnoses? Had their cultures attached different meaning to their disturbances of thought, mood, or behaviour? Perhaps. But could it ‘simply’ be that what grants purchase to ‘these kinds of stories’ is the absence of effective interventions to render their staying power superfluous?
Identity is a peculiar, evolving and flexible concept. It comprises many elements but only, I would argue, certain diagnoses: those not (yet) rendered superfluous by medicine’s growing reach. My ‘hypertensive’ diagnosis contributes little or nothing to my identity because it is held in check by tiny tablets, as are my anxiety and depression. Consider this: now that syphilis, tuberculosis and HIV have been tamed by antibiotics and antivirals, could Bram Stoker write Dracula today, or Thomas Mann The Magic Mountain, or Tony Kushner Angels in America? Were the equivalent game-changing interventions for anxiety or depression to emerge tomorrow or schizophrenia the following day, would those signify the end of the mental illness memoir or case study?
Much as I admire the intimacy, empathy and originality of Ms Aviv’s stories and her reportorial restraint, I think she misses an opportunity to say something new and profound – to squeeze her sources more tightly in the hope that they might yield more juice (a criticism which, I readily concede, may be unfair on my part). But her stories – when considered holistically – come so close to suggesting there must be more, that it’s difficult not to feel frustrated that ‘that’s all there is’.
I cannot help but wonder if something else is going on. It could simply be this: that the author is too great a journalist to allow her own views to take precedence over those of the ‘experts’ whom she cites – even if, as Professor Scull (2022) argues and Ms Aviv surely knows better than most, when it comes to psychiatry and mental illness, there are no experts to be had – certainly none who know and have thought more about these issues than she has herself. What her commendable humility denies her (and us) is an opportunity to exploit her own hard-earned, robust and nuanced perspective – if you will, her expertise – which she has acquired over the course of a lifetime of reading, writing and thinking deeply about the issues her magnificent stories and her remarkable tellings bring to life.