There are thousands of nonfiction books about mental health whose chapters bend towards an epiphany presented first on the cover. Like that Americans are over-medicated, or scientists have determined a new origin of consciousness, or a man really can mistake his wife for a hat. Rachel Aviv’s first book of reported essays, Strangers to Ourselves — and much of her feature-writing over the past decade — belongs to this genre, but stands out by virtue of how successful she is in the attempt. In fact at moments it feels quite far from the fray, perhaps because (as its enigmatic title suggests) her pieces, even her sentences, tend to conclude ambivalently, and are driven throughout by a curiosity that resists its own moral and rhetorical instincts, forging narrative ones instead.
The piece that introduced me to Aviv’s work — her first for the New Yorker, where she’s now a staff writer — is about a woman named Linda who has received from many doctors a diagnosis of bipolar disorder with psychosis but does not believe she has a mental illness. The first fifth of the piece wouldn’t seem out of place in an Ottessa Moshfegh story (I say this from a position of neutrality): Linda breaks into an empty farmhouse and decides to stay, slowly wasting away from a diet of apples. She reads Joseph Conrad and spies on her neighbors. According to journal entries left behind in one of the former occupant’s leather notebooks she could find “no signs or clues that I should be doing anything different.” Later, it’s revealed that one of Linda’s delusions involves a subplot related to 9/11.
Between these cannily crafted narrative sections, Aviv introduces an idea which becomes central to Strangers, that of “insight.” In a diagnostic sense the term refers to the patient’s ability to articulate the nature of their mental illness as understood by the medical establishment they’ve come into contact with. This information can be important for evaluating a patient, but Aviv carefully points out its limits. “Stories about psychiatric illness are often deeply individual,” she writes, “the pathology emerges from within and is endured that way, too. But these stories neglect where and how people live, and the ways their identity becomes a reflection of how others see them.”
To capture the proliferations and incongruities of identity, Aviv chose six subjects for Strangers who were given mental health diagnoses and wrote records of their lives, including herself. With the exception of Aviv, these accounts were published minimally or not at all. Some take the form of diaries. Aviv tends to choose quotes that reveal more than the subject is intending to say, and the morsels of these texts that appear in Strangers are rich ground for layered readings: poetic, humorous, impassioned, or else curiously vacant.
Take the case of Ray Osheroff, a nephrologist who began exhibiting extreme anxious behavior. In 1979, Ray was admitted to a professionalized but eccentric psychiatric facility known as the Lodge, which was committed to talk therapy as its sole medical intervention. When this treatment didn’t alleviate Ray’s symptoms, he checked into another facility called Silver Hill, which a 1964 Trends in Psychology paper had described as full of artists, executives, surgeons and “a sprinkling of under-achieving and guilt-ridden college students of good family” who were encouraged “to find non-pathological topics of conversation.” It was here that Ray received prescriptions that made a difference in his mental health, and he wound up suing the Lodge for failing to medicate him during his stay, an experience he eventually detailed in his memoirs. The title alone is more salacious and grammatical than the contents of entire gossip rags: A Symbolic Death: The Untold Story of One of the Most Shameful Scandals in American Psychiatric History (It Happened to Me).
Another subject, Laura Delano, grew up in the wealthy, white milieu of Greenwich, Connecticut, where she fulfilled the expectations of her class by excelling at everything, seemingly without undue effort. In eighth grade, depressive symptoms emerged for which Laura was given her first diagnosis of bipolar disorder, and medication, inaugurating a decade of prodigious fealty to the expertise of her doctors and their prolific scrip pads. A notebook from college is saturated with the flagellating logic of compulsory self-improvement. “Overanalysis must go,” she writes, and “Find some faith in something, in anything.” Aviv was far younger, only six years old, when she experienced her first brush with psychiatric care. After barely eating for many days she was admitted to the Children’s Hospital of Michigan with a diagnosis of anorexia, a concept she’d of course not previously been acquainted with, and it was not the only one. About feeding tubes she writes, “I didn’t realize that the tube would go inside my nostrils. I imagined a huge tube, like a covered slide, that I would live inside.”
These subjects give vivid accounts of themselves, not entirely faithful or unimpeachable ones. Doctors don’t necessarily fare any better in that department. Aviv writes that, “Although the Lodge’s philosophy was that every patient deserved understanding, Ray’s medical records suggest that his doctors did not like him.” Notes from Aviv’s time at the psychiatric hospital describe her gracefully, though not altogether accurately, as a “well developed but very thin female in no acute distress.” Nor is the power imbalance between doctor and patient always so charmingly askew. At its worst it can condone state violence, brutal calculus, the suspension of liberties. As Naomi Gaines nears the end of her prison sentence for causing the death of one of her children and threatening the life of another during a delusional episode, the prison’s Special Review Board exhibits psychiatrists’ records as evidence of Naomi’s mental unfitness to leave the facility at her appointed date. Naomi is Black, grew up without much money, and, unlike Laura, was chronically under-medicated, including during her period of incarceration. The Board cites her fear of being gassed, which they consider to be irrational, as evidence in favor of her continued imprisonment. Gaines uses her own psychologist’s notes to remind them that during her time in prison officers did in fact gas her, before throwing her into solitary confinement.
Far from delegitimizing her main subjects, Aviv’s method lends their accounts immediacy and weight.
Self-deceiving doctors, spoiled plans, compounded prejudices, linguistic misunderstandings huge enough for a person to live inside of. Already you can begin to see how Aviv’s writing over the years — and now in this collection — injects more life into so many questions at the intersection of mental health, politics, culture, and justice. My notes on where to focus this short piece about her work are neurotically broad: “individual vs. collective,” “art and madness” “civilization and its discontents.” But in trying to articulate what makes Aviv’s writing so generative and particular I keep gravitating to her style, unusual for a reporter or essayist exploring the “psychic hinterlands,” as Aviv puts it, “where language tends to fail.”
A reverence for scientific method, persuasive argument, and sound conclusions are conventions of writing that takes up such issues. I’m thinking of the sort of New York Times feature that deploys its roster of interview subjects as neatly delineated examples of national crises in criminalization and care. Then there are pieces with a more literary bent, those that are largely concerned with the representation of other minds, and consider questions like: Can empathy be elicited or reproduced in writing? What sort of narrative emphasis on traumatic events would yield the truest result? Of course the representation of other minds is central to Aviv’s work as well, but she proceeds from the position that everyone’s narrative is porous, protean, and at times unreliable. Setting aside all the performative aspects of empathy, how can you feel what another person is feeling if they don’t know what they themselves feel, or if they don’t want to tell you?
Far from delegitimizing her main subjects, this method lends their accounts immediacy and weight. Form and style bring their narratives into greater relief. What she writes are profiles that often open up from a single subject, someone both marginalized and warped by mainstream cultural fantasies of the good life. This subject comes into contact then becomes locked in conflict with some kind of large institution whether it be prison, hospital, elite university, law enforcement, or border control. Their memories are partial, fragmented, vulnerable to external forces — but then, so are the institutions’. When Aviv appears in her reporting it is to offer a brisk counterweight to a subject’s analysis or to ask a question that receives a surprising answer. A fly lands on the text, swizzles its appendages, and alights again before you had even thought to swat it away.
The main stylistic departure for Aviv in Strangers is to write the first essay, and significant portions of the last two, about her own experiences as a reporter and patient. It turns out the disintegration of a much relied-upon analytic structure can be quite satisfying for the reader, and it gives Aviv the freedom to address some of her unwieldy preoccupations more directly. A big one in Strangers, given her heterodox exploration of insight, is why some people find meaning in their diagnoses, while others don’t. “At six years old, it still seemed possible that I could become someone else through sheer will,” writes Aviv. In the end anorexia “didn’t provide the language with which I came to understand myself.” But it did bound her story in another way. Aviv writes that the experience made her more sensitive to moments when a person’s self-conception becomes seeded with discord or is radically overthrown. It is somewhere around this moment that Aviv materializes on the scene. Clues accumulate without ever snapping into a coherent explanation. Someone else’s leap of imagination has become the knot at the center of her work.
“People rarely lack insight in an absolute sense,” writes Aviv in her profile of Linda, noting that a patient can both believe he’s God’s own son and take out the trash at night. That’s not even multitasking. But is it possible to have too much insight? In Strangers those who identify with their insight most acutely are also most susceptible to feeling their lives have been vacated of meaning. In the throes of despair Laura writes about experiencing a “pure and unadulterated loneliness” and doubting whether she has a “real self underneath.” Shortly after leaving the Lodge, Ray describes himself, in what sounds like a line from Samuel Beckett’s Molloy, as “a homeless man with only a mother.” At hearings in his case against the Lodge he testified about his time there. “I would say to myself, ‘I am living, but I am not alive.’”
Whereas the third subject of Aviv’s book, Bapu, is more of a Simone Weil type, indulging in rejection and devotion. In the ’60s her wealthy Brahmin family arranged for her to have a house in Chennai and a husband, with whom she had two children. At first she agreed to all of it, then she changed her mind. Her religious fervor intensified. At the same time she became infatuated with the sixteenth-century poet Mirabai and began producing her own verses prolifically, often believing she and Mirabai were one. Then she started running away from home, sleeping in local temples and railway stations. Aviv writes that Bapu, “didn’t want to continue living what she called ‘a meaningless life.’ She was disgusted by the money spent at her wedding and by the idea that anything was her property.” Her husband took her to a psychiatric clinic where a doctor told her she had schizophrenia, a diagnosis that in India has its own long, fraught history. As she continued to run away and be fetched back, Bapu’s stints at various Indian hospitals began to mirror the way she was in and out of another institution, her family, the members of which also became adept at furnishing all kinds of explanations for her behavior. However, like Linda, Bapu rarely felt there was any truth in her diagnosis.
Aviv asserts that, having undergone this transformation, “Bapu was not trying to arrive at an understanding of her own psyche; she wanted to transcend personal boundaries, because she felt that she was finally grasping the folly and loneliness of her prior view of the world.” I am impressed by Aviv’s deft manipulation of studies, academic treatises, doctor’s notes, and interviews, but I am moved by her commitment to weaving uncertainty, mystery, and devotion into these narratives as well. It’s writing that aspires to spare nobody the anguish of its ambivalence, and yet helping to illuminate a subject’s particular suffering or ecstasy can be a gift. At its best the words wield this dimensionality like a threshold, which I envision not as a window onto a subject’s soul, but like a door that stays open for anyone wishing to be welcomed as a stranger.
Hannah Gold is a critic and fiction writer based in NYC.