Rachel Aviv’s book, Strangers to Ourselves, is part memoir, her experiences book-ending a collection of five case-studies that focus on people struggling with their mental health.

Each of the case studies exposes the challenges of a mental health diagnosis, the stigma associated with some conditions, and the prejudices particular groups of people face.

Mental-health institutions were not designed to address the kinds of ailments that arise from being marginalised or oppressed for generations.

I found so many elements of this book thought-provoking, and paused my reading frequently to reflect on the detail in each case study. One focuses on an Indian woman, Bapu, who lives in the healing temples in Kerala, and has devoted her life to mysticism. However, Bapu had left the comforts of her wealthy family life and ‘escaped’ institutional care a number of times in order to follow the voices guiding her. By Western standards (with which her family were ‘treating’ her) she might be considered schizophrenic. But ‘…the metrics by which Bapu assessed her own state of mind were murkier, because she drew from a rich tradition that gave her anguish purpose and structure.’

One line stopped me in my tracks, reminding me of a client I had many years ago who was looking after a family member with schizophrenia. The family member had many highly unusual behaviours, what most would describe as ‘paranoid’. I discussed the case with my clinical supervisor (who is a narrative therapist, and always gives me a different perspective), and she asked me, “What if X [the person diagnosed with schizophrenia] is ‘right’ and thinks we’re all strange? Their world contains all the things they talk about…that’s not say they’re not there.” And I thought about how it would be to live in my client’s world, and their family member’s world. And so, when Aviv says of Bapu leaving her family and their ‘care’ –

Her inner world had come to feel more substantial than the reality to which her family was bound.

it resonated strongly. The idea of an inner world being more compelling or more safe than the outer applies broadly, and not necessarily associated with a mental health diagnosis.

The other case studies were equally as interesting. The first provided context for the whole book as it was about a man called Ray who was the embodiment of the clash between ‘…two opposing theories of the mind…’ (the medical model versus treating with therapy, in this case, psychoanalysis). On the ‘expected epiphany’ that comes with psychoanalysis –

…it became apparent that gaining insight into interpersonal conflicts, though intellectually rewarding, did not provide a cure.

There is a strong divide between the medical and therapeutic models – essentially in Western society we tend towards pathologising. Aviv states –

For more than fifty years, scientists have searched for the genetic or neurobiological origins of mental illness, spending billions of dollars on research, but they have not been able to locate a specific biological or genetic marker associated with any diagnosis. It is still unclear why antidepressants work.

I wonder what would happen if we let go of the idea of a ‘cure’ as the ultimate endpoint for a person’s mental health challenges and instead sought ways for them to live the best they can within the parameters they have? (See this recent Insta post by Robbie Williams).

Other case studies include the heartbreaking case of Naomi, a Black woman, who, during a psychotic episode, killed her child. She was jailed, and over the following years sought to understand what had happened for her. Naomi’s story highlighted the significant inequality in the US health and justice system. For women of colour (who have less access to mental health care) –

…once they were incarcerated, their struggles were more likely to be considered acts of defiance than signs of illness.

In contrast, the case study of Laura, a wealthy white woman, who grew up with every possible advantage, tells of her long history of various diagnoses (including bipolar disorder and borderline personality disorder) and an even longer list of medical and pharmaceutical interventions.

While Black women tend to be undermedicated for depression, white women, especially ambitious ones, are often overmedicated, in order to ‘have it all’: a family and a thriving career.

Laura ultimately decided to do away with her medications. At this point, Aviv reflecting on her own experience with a particular anti-depressant states ‘…perhaps the medications had changed me so much that my baseline self was no longer mine to reclaim…’, which is essentially the struggle Laura had in terms of her diagnoses being part of her identity.

Aviv’s story begins and finishes this book, and it is astounding. Aviv was diagnosed at age six with anorexia, although she had no understanding or language for what she was experiencing at the time –

…I was ‘recruited’ for anorexia, but the illness never became a ‘career’. It didn’t provide the language with which I came to understand myself.

And yet, the experience of being hospitalised and ‘studied’ left their mark.

Not sure who to recommend this book to but know that Aviv’s even-handed treatment of each case (there’s no hint of lecturing to her readers) makes for interesting reading.

4/5