Strangers to Ourselves: Unsettled Minds and the Stories That Make Us

by Rachel Aviv

A large body of studies has found a greater incidence of psychosis in communities with less “ethnic density”—the proportion of people from the same ethnic group. For people of color, the risk of psychosis rises the whiter their community is. They are more likely to feel alienated and alone and to be targets of discrimination.

“When it comes to affluent white patients you can take care of moral blame using a biological explanation,” she said. These families often feel freed by the idea that an illness is no one’s fault. “But when it comes to Black and brown and poor patients, that same biological explanation is used to deflect blame away from the societal forces that brought them where they are. Because there is moral blame: the blame of having disinvested in people’s communities by doing things like taking away affordable housing or protection for workers.” She said that her patients have found it therapeutic and empowering when she acknowledges the societal structures that have contributed to their state of mind.

Helena Hansen, Psychiatrist / Anthropologist, UCLA

“the pain has to go somewhere—it can’t disappear,” Smith said. “It doesn’t simply dissipate. You pass it on.”

intergenerational trauma

“I have survived the darker aspects of myself,” she wrote in the book. “What I’ve done and where I’ve been is not who I am.”

“They say, ‘Take your meds, just take your meds,’ as though everything will be okay,” she complained, according to her prison records. “It is not okay and it doesn’t ‘just go away.’”

“Ms. Smith wasn’t treating me like a problem to be fixed only with medication. She understood the language I was speaking. She knew me intellectually, philosophically, and even on some level spiritually. She was a huge barometer to judge my wellness and nonwellness.” After the visit, Naomi began taking Tegretol again. Perhaps if Naomi had encountered this kind of understanding years earlier—someone who grasped the different frameworks necessary to describe her pain—she would have had a different “career.” Her delusions might not have taken hold so firmly if she hadn’t felt so alone.

The oldest of three sisters, Laura felt as if she were living two separate lives, one onstage and the other in the audience, reacting to the performance. She felt exhausted by the effort, which made her feel as if she had an “empty core.” She didn’t want to pursue what she called the “good-girl model of life,” fulfilling the prim ideals of Greenwich society.

“Why do I have these extra layers of thought that others don’t have and that pull me farther and farther away from being human?” she wrote in her journal. Each day felt like a new performance. “In the morning, I had to get myself motivated enough to shower and change and go be Laura Delano,” she said.

Her smile is pinched and dutiful. She performed the required motions, walking to the stage and curtsying again. But by the end of the night, drunk on champagne, she was sobbing so hard that her escort had to put her in a cab. She felt “pure and unadulterated loneliness,” she said. In the morning, she told her family that she didn’t want to be alive. She took literally the symbolism of the parties, meant to mark her entry into adulthood. But she didn’t believe in the adult she was supposed to become. She told me, “I was trapped in the life of a stranger.”

masking

When she looked in the mirror, she felt little connection to her reflection. “All I ever want to do is lie in my bed, cuddle with my dog, and read books from writers whose minds I can relate to,” she wrote a psychiatrist. She identified intensely with Sylvia Plath, another brilliant, privileged, charismatic young woman who, in her journal, accuses herself of being just another “SELFISH EGOCENTRIC JEALOUS AND UNIMAGINATIVE FEMALE.” To avoid madness, Plath wonders if she should devote “the rest of my life to a cause—going naked to send clothes to the needy, escaping to a convent, into hypochondria, into religious mysticism, into the waves.”

The theory of the chemical imbalance, which had become widespread by the nineties, has survived for so long perhaps because the reality—that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors—is more difficult to conceptualize, so nothing has taken its place. In 2022, Thomas Insel, who directed the National Institute of Mental Health for thirteen years, published a book lamenting that, despite great advances in neuroscience, when he left the position in 2015, he realized, “Nothing my colleagues and I were doing addressed the ever-increasing urgency or magnitude of the suffering millions of Americans were living through—and dying from.”

“I never had a baseline sense of myself, of who I am, of what my capacities are,” she said. She wanted to somehow strip away the framework that had been imposed on her identity. The doctors at the borderline clinic initially resisted her request to stop her medications, but they also seemed to recognize that her struggles could not be fixed with technology. A few months earlier, one doctor had written on a prescription pad, “Practice Self-Compassion,” and for the number of refills he’d written, “Infinite.”

T_T <3

Once the chemical-imbalance theory became popular, mental health became synonymous with an absence of symptoms, rather than with a return to a person’s baseline, her mood or personality before and between periods of crisis. Dorian Deshauer, a psychiatrist and historian at the University of Toronto, told me, “Once you abandon the idea of the personal baseline, it becomes possible to think of emotional suffering as relapse—instead of something to be expected from an individual’s way of being in the world.”

But that question—“Am I the insane one, or is it society?”—diminishes the reality of mental disability and presumes the impossible: that the self can be divorced from the society that shapes it.

A common theme on the forums was that people felt that at some point, having taken numerous medications for years, they’d become disabled, and they were no longer sure if it was due to their underlying disorder, the heavy medications they’d taken for it, or the way their families or communities had responded to them—a process that sometimes coincided with the pressure of needing to prove their disability, in order to receive social security benefits. Swapnil Gupta, a professor at the Yale School of Medicine, told me that when her patients express fear about stopping their medications, their concerns are often about social and financial problems as much as about medical ones. “Some people worry they will lose their disability payments because being on lots of meds has become a badge of illness,” she said. For others, “the pills represent an attachment to a physician, and taking away that medication means they are losing that attachment.” She went on, “It is a loss of identity, a different way of living: suddenly everything that you are doing is yours, and not necessarily your medication.”

there is a difference, of course, between lonely sadness and the kinds of deprivations that defined Naomi’s history—and the cognitive dissonance when those wrongs were not acknowledged, the sense that reality could not be trusted. Yet psychiatry approaches these sets of troubles in the same way, adopting a position of neutrality that can feel violent. What can a psychiatrist say, Elliott asks, to “an alienated Sisyphus as he pushes the boulder up the mountain? That he would push the boulder more enthusiastically, more creatively, more insightfully, if he were on Prozac?”

one must imagine Sisyphus on Prozac 🥴

The sociologist Alain Ehrenberg writes that long-term treatment with antidepressants has become a cure for people who feel inadequate. The drugs create a “paradoxical situation, in which the medication is invested with magical powers while the pathology becomes chronic.” Helen, who stayed off Lexapro, believed there had been something phony about her sudden desire, while medicated, to be part of the world. I, too, found it foreign. But it also felt true. “It is joy to be hidden,” the British psychoanalyst D. W. Winnicott wrote, “but disaster not to be found.”

In her book Depression: A Public Feeling, the scholar Ann Cvetkovich writes that if depression can be “conceived of as blockage or impasse or being stuck, then its cure might lie in forms of flexibility or creativity more so than in pills.” I am drawn to this idea, though I don’t think these two strategies are in opposition. I also realize that I’ve endowed my pill of choice with mystical capacities—it contains the things I’m not but wish I was—and merely the idea of swallowing such a thing has healing power. I wish I had a more flexible approach toward my feelings of inadequacy (“I want to be someone better than me,” I had written in my second-grade diary), but I also feel closer to that space of flexibility when I take Lexapro; it seems to relieve the cognitive rigidity that often accompanies anxiety and depression—the sense that one’s story can unfold only one way.

“If I actually sat in front of a psychiatrist and did an evaluation, I would totally meet the criteria for a number of diagnoses.” But the diagnostic framework no longer felt meaningful to her. Bianca, who was still struggling to let go of the idea that depression explained who she was, said, “It’s like your darkness is still there, but it’s almost like it’s next to you as opposed to your totality of being.” She added, “But I know you haven’t come out the other side.” “It’s not like I’m good to go,” Laura agreed. “Literally every day I am still wondering how to be an adult in this world.”

Mental disorder can feel uncertain and liminal, but it can also be more straightforward, a tragedy that overwhelms people’s capacity to think and connect.

“Children with significant psychiatric illness are tolerated for a period of time when they are cute and cuddly and small,” he responded. “But once it goes beyond that period, it is tremendously upsetting for older people, in terms of their own anxieties. And then, at some magical point—I’m not sure you can define it—these children, instead of generating empathy, become uncomfortable freaks.”

THE POET LOUISE GLÜCK, who was anorexic, wrote, “The tragedy of anorexia seems to me that its intent is not self-destructive, though its outcome so often is. Its intent is to construct, in the only way possible when means are so limited, a plausible self.”

Ray, Bapu, Naomi, and Laura also felt compelled to write about their illnesses, even as they realized that the language on offer wasn’t quite right. They described their psychological experiences with deep self-awareness, but they also needed others to confirm whether what they were feeling was real. It didn’t matter whether they believed they were married to God or saving the world from racism—they still looked to authorities (mystics for Bapu, doctors for the others) to tell them how and why they were feeling this way. Their distress took a form that was created in dialogue with others, a process that altered the path of their suffering and their identities too.

Deegan challenges the idea that, after the disruption of mental illness, people can slip back into their former identities. “For those of us who have struggled for years, the restitution storyline does not hold true,” she writes. In another essay, comparing herself to a friend who was paralyzed from the neck down, Deegan writes, “Recovery does not refer to an end product or result. It does not mean that the paralyzed man and I were ‘cured.’ In fact, our recovery is marked by an ever-deepening acceptance of our limitations.” She proposes that “transformation rather than restoration becomes our path.” Deegan acknowledges that some phases of recovery require planning and work, but not every part of the process can be consciously orchestrated. “All of the polemic and technology of psychiatry, psychology, social work, and science cannot account for this phenomenon of hope,” she writes. “But those of us who have recovered know that this grace is real. We lived it. It is our shared secret.”

Pat Deegan, pychologist

She began sleeping over at Tim’s apartment nearly every night. Once, when he came back from work at the end of the day and she was still in bed, nine hours later, he gently suggested that tomorrow she should try to move to the couch. “I talked about my own struggles and how even if I don’t want to do anything all day I’ll get dressed,” he said. “I’ll make myself food—it’s the tiniest, tiniest little things. You’re never going to have a big breakthrough. But there are a lot of tiny breakthroughs, and they add up.” Years before, during a period of semi-recovery, Hava had written in her journal that she felt like the turtle in The Grapes of Wrath who attempts to cross a highway. With “old humorous frowning eyes,” the turtle drags himself across the hot pavement, even after his shell is clipped by a speeding truck and he flips onto his back and off the road. The turtle rights himself and slowly inches forward. “How good it would be to absorb a rain or even a light drizzle,” Hava wrote. “But for now he travels on.”

He began crying, and I apologized for asking him to recount events that were still so fresh. “And I hope it never goes away,” he said. “A lot of times your own sufferings—how you deal with your suffering—helps people. More than you will ever know.”

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