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

by Rachel Aviv

The philosopher Ian Hacking uses the term “looping effect” to describe the way that people get caught in self-fulfilling stories about illness. A new diagnosis can change “the space of possibilities for personhood,” he writes. “We make ourselves in our own scientific image of the kinds of people it is possible to be.”

Although a purely psychiatric model of the mind may be essential to the survival of people with mental illness, the title of this book, Strangers to Ourselves—a phrase that comes from Hava’s journal—is a reminder that this framework may also estrange us from the many scales of understanding required, especially in periods of illness or crisis, to maintain a continuous sense of self.

This book is about people whose struggles with mental illness exist outside of this “closed and completed system of truth.”

The divide between the psychic hinterlands and a setting we might call normal is permeable, a fact that I find both haunting and promising. It’s startling to realize how narrowly we avoid, or miss, living radically different lives.

The chemical-imbalance theory was first described in 1965 by Joseph Schildkraut, a scientist at the National Institute of Mental Health, in what became the most frequently cited paper in The American Journal of Psychiatry.

He reasoned backward: if antidepressants worked on those neurotransmitters, then depression may be caused by their deficiency. He presented the theory as a hypothesis—“at best a reductionistic oversimplification of a very complex biological state,” he wrote.

She hadn’t realized that the idea that depression was caused by a chemical imbalance was just a theory—

For more than fifty years, scientists have searched for the genetic or neurobiological origins of mental illness,

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. 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.

The bioethicist Carl Elliott writes that for some people antidepressants do not address an inner psychic state so much as “an incongruity between the self and external structures of meaning—a lack of fit between the way you are and the way you are expected to be.”

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.”

The psychoanalyst Adam Phillips has said that “everybody is dealing with how much of their own aliveness they can bear.” It was as if Lexapro directly acted on this capacity. Without the drug, I lacked the courage to try something new. In Roland Kuhn’s terms, I had lost the “power to experience.”

In Listening to Prozac, Kramer asks whether some people might feel pressure to take medications, as they watch their colleagues and friends take the drugs and become, in a social and emotional sense, upwardly mobile.

I wanted my children to remember the version of me that took Lexapro.

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.