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

by Rachel Aviv

Hava, who weighed seventy pounds, seemed conflicted about whether her mother’s explanation improved her social status. In her journal, she listed “what I wish I could like about myself,” which included “my personality,” “my intelligence—my grades,” and “my feelings.” She had dreams in which she was “pleading with my peers and suddenly I received their total acceptance and understanding,” she wrote.

The French philosopher René Girard describes anorexia as being rooted in “the desire not to be a saint but to be regarded as one.”

For a child, solipsistic by nature, there are limits to the ways that despair can be communicated. Culture shapes the scripts that expressions of distress will follow. In both anorexia and resignation syndrome, children embody anger and a sense of powerlessness by refusing food, one of the few methods of protest available to them.

Mental illnesses are often seen as chronic and intractable forces that take over our lives, but I wonder how much the stories we tell about them, especially in the beginning, can shape their course. People can feel freed by these stories, but they can also get stuck in them.

Studies show that people of color are rated as “lacking in insight”22 more often than those who are white, perhaps because doctors find their mode of expressing distress unfamiliar, or because these patients have less reason to trust what their doctors say. In the starkest terms, insight measures the degree to which a patient agrees with his or her doctor’s interpretation.

Freud’s 1917 paper “Mourning and Melancholia.” In the essay, Freud had proposed that melancholia arises when a patient is mourning something or someone but “cannot see clearly what it is that has been lost.”

Other hospitals were giving patients barbiturates, a sedating drug, as well as electroconvulsive therapy and lobotomies. But Dexter believed that “pharmacology has no place in psychiatry.”11 At a medical society conference, when Dexter’s colleague reported that he had lobotomized a patient and cured her in ten days, Dexter objected to the idea of a treatment that didn’t even require self-knowledge. “You can’t say that!”12 Dexter shouted.

Fromm-Reichmann described loneliness as “one of the least satisfactorily conceptualized psychological phenomena, not even mentioned in most psychiatric textbooks”15—a state in which the “fact that there were people in one’s past life is more or less forgotten, and the possibility that there may be interpersonal relationships in one’s future life is out of the realm of expectation.”16 Loneliness was such a deep threat, she wrote, that psychiatrists avoided talking about it, because they feared they’d be contaminated by it, too. The experience was nearly impossible to communicate; it was a kind of “naked existence.”

“The symptoms and the sickness and the secrets have many reasons for being,”40 Greenberg, who had been diagnosed with schizophrenia, wrote. “If it were not so, we could give you a nice shot of this or that drug.” But, she wrote, “these symptoms are built of many needs and serve many purposes, and that is why getting them away makes so much suffering.”

Gruber said at the meeting. “I guess what I am trying to bring out is the destructive element and that maybe this is how he will do with us—destroy our availability to him as he has destroyed her availability to him.” Ross agreed. “He treats women as if they are the containers for his anxiety and are there to indulge him and pat his hand whenever he’s in pain,” he said. “And he does that with me, too, you know—‘You don’t know what pain I’m in. How can you do this to me?’”

“I had some sense hearing people talk today that people think he is in some way kind of a bad person who talks like he’s a big shot and sort of feel that he really isn’t very important and big and to hell with him.” He said that Ray seemed to him “very much a genuine little boy.”

He asked Ross, “Will I ever grow old with my children around me?” In his memoir, he wrote that Ross replied, “You, a patriarch? How absurd. How utterly absurd. You, a patriarch? Ha, ha ha.”

A psychiatrist, Kuhn wrote, must understand that he is “not dealing with a self-contained, rigid object, but with an individual who is involved in constant movement and change.”52 Sometimes, Kuhn said, after taking medications his patients realized they had been ill for much longer than they had known; they began to reassess who they had been all along.

Reviewing antidepressant studies and clinical trials in both animals and humans, Schildkraut proposed that the drugs increased the availability of the neurotransmitters dopamine, norepinephrine, and serotonin—which play a role in the regulation of mood—at receptor sites in the brain. 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,”

The New York Times wrote that the case shook “the conventional belief, held even by some doctors, that chronic depression is not an illness, but merely a character flaw.”

In “Dostoevsky and Parricide,” Freud writes that, when a son discovers that his father has been killed, “it is a matter of indifference who actually committed the crime; psychology is only concerned to know who desired it emotionally and who welcomed it when it was done.”

But Indian healing cultures were meant to raise the self to a higher ideal—detached, spontaneous, free of ego—rather than simply to restore the person to a baseline called normal.

The ashram was devoted to the mystic Sri Aurobindo, who said, referring to Freud, “One cannot discover the meaning of the lotus by analyzing the secrets of the mud in which it grows.”

Disagree. The terroir is what influences epigenetic expression. The lotus wouldn't exist in that form without that mud.

The new explanation felt like an affront, which isn’t to say that her previous reputation was free of stigma either. Psychiatry isn’t the only framework that has a kind of double-edged quality, offering a story that can save a person but that also, under different conditions, feels lonely and intractable.

Ramakrishna, a nineteenth-century mystic, told his devotees that madness was a mark of devotion and should never be mocked. “A perfect knower of God and a perfect idiot have the same outer signs,”49 he wrote. The eighteenth-century Hindu poet and saint Ramprasad promised, “In heaven there is a fair of lunatics.”50

At the hospital, Bapu was not treated as a credible witness to her own experiences, not only because of her status as a patient but also because of colonial notions about the irrationality of Indian religions.

“The garment that we call ‘this body’ has come to one person as a child, to another as a wife, to another as a mother, to another as an enemy, and to some as a friend, and it perishes entirely,” she wrote. “Why be sad about it! It’s the fate of the world.”

one story, a mother has gone mad after the death of her baby and begs the Buddha for medicine to revive her child.63 The Buddha agrees, with one condition: she must procure a mustard seed, a cheap Indian spice, from a family in which no one has died. Elated, the mother begins knocking on doors. By the end of the day, though, she realizes that no houses are free of death. The mother comes to see her grief as part of a universal problem of existence. She finds solace in generalizing her hopelessness from herself to the world.

“We should welcome—rather than fear misuse of—evidence that psychopharmacological and neurophysiological frameworks are not the only ones pertinent to effective psychiatric practice,”68 they wrote.

“The much talked about ‘stigma’ surrounding the mentally ill is at some fundamental level a problem about not having an ordinary, existential language for talking about mental distress,”70 Bhargavi wrote.

a line from a poem by Saul Williams: “Our stars and stripes / Using blood-splattered banners as nationalist kites.”3

Her aunt had washed imaginary dishes in an alley, but no one had ever labeled her mentally ill. Other relatives seemed a little too angry. “I understood that,” Florida said. “But mentally ill? No.” Florida told me, “In our family, if you feel a little down you just take a nap. That’s the solution: take a nap.” Mental-health institutions were not designed to address the kinds of ailments that arise from being marginalized or oppressed for generations. Psychotherapy has rarely been considered “a useful place of healing for African Americans,”20 wrote the scholar bell hooks. For a Black patient to reveal her fears and fantasies to a therapist, trained in a field that has been dominated by middle-class white people, requires a level of trust that hasn’t typically been earned.

“Melancholy registers the experience of being rendered invisible, of being both assimilated into and excluded from the social order.”32 Barred from full recognition, the grief never resolves.

“It is as though some great, great, great wound is in the whole body, and no one dares to operate: to close it, to examine it, to stitch it.”

THREE YEARS AFTER moving to Minnesota, Naomi slit her wrist. She didn’t really want to die, she said, but “the pain I was experiencing was so great that I just wanted to hurt myself, so I could have something else at the forefront of my mind.”

Naomi was discharged with a prescription for the antidepressant Zoloft, but she stopped taking it after a few weeks, because it made her tired and she didn’t believe it would work. Drugs will not “change the heartache in the world,” she had told her psychiatrist. To be her true self, Naomi felt, required suffering in the face of a racist and violent reality.

For much of the last hundred years, the suicide rate for African American adults has been roughly half that of white people, a finding that may be complicated by stigma and neglect.51 (Suicides may end up classified as other forms of death, like overdoses or accidents.)

The Martinique-born psychiatrist and philosopher Frantz Fanon set a similar goal—psychiatry had to be practiced with a “brutal awareness of the social and economic realities,”66 he wrote. But most of Fanon’s analysis was focused on men. Some “may ask what we have to say about the woman of color,”67 he acknowledged in his 1952 book, Black Skin, White Masks, about how racism and colonialism affect the male psyche. Whether because of a lack of studies or because the literature was marred by stereotypes, his answer was straightforward: “I know nothing about her.”68

For people of color, the risk of psychosis rises the whiter their community is.79 They are more likely to feel alienated and alone and to be targets of discrimination.

felt like someone hit me with a hammer and opened my mind to things I wasn’t privy to,” she told me. “It could be called a moment of clarity, but it was much more psychologically violent than that.”

Until her crime, psychiatrists had seemed unwilling to engage with her remarks about race except as “bizarre” pathology. These doctors recognized the validity of her insights about society—it was the first time her perspective had been validated at an institutional level—but only to use them against her, as evidence that she deserved to be punished.

“Prisons don’t disappear problems, they disappear human beings.”

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

But the shock and humiliation of losing seven children seemed to have exacerbated Velma’s condition—an experience Florida came to understand when, a few years later, her firstborn, Toma, was taken away, too. “If you think you are not a good enough mother, then you carry yourself different,” she said.

Jorgensen observed that the women of color were less likely than white women to have had access to mental-health care before prison, and, once they were incarcerated, their struggles were more likely to be considered acts of defiance than signs of illness. Nearly all of Jorgensen’s patients had experiences of trauma: physical or sexual abuse, incest, domestic violence, rape, abandonment. Arthur Blank, one of the first psychiatrists to recognize the struggles of Vietnam veterans who returned from the war, characterized trauma as an experience that a person doesn’t have “the capacity to integrate, digest, narrate … a foreign body in the psyche.”

Hawes spoke with women who had been placed in solitary confinement for a range of infractions, including singing at the wrong time, eating someone else’s piece of cake, or violating the prison’s no-touch policy. The women at Shakopee were not allowed to hug, give one another high fives, link feet below a table, or braid one another’s hair. Naomi said that in the courtyard, on sunny days, she and other women would manipulate their shadows so that they could have the illusion of hugging without breaking the rules.

But sometimes Naomi resented the idea that all biologies are universal. She wanted to tell her doctors, “Your mental break could never be my mental break. We have different fears than white people, so you’re going to miss the mark.” She said it felt like, “I’m coming to the doctor for a headache, but you’re looking at my knee?”

The concept of borderline personality disorder emerged in medical literature in the 1930s, for patients whose symptoms didn’t fit any other diagnoses. Harold Searles, a psychiatrist at Chestnut Lodge, described these patients as too “audience-oriented”15: they patterned their sense of identity on other people’s expectations. In 1980, the diagnosis was added to the DSM, which noted that “the disorder is more commonly diagnosed in women.”16 Its defining features, which include excessive emotions, lack of self-control, and a fragmented sense of self, seem to pathologize stereotypically feminine traits.

that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors—

Another word that members used was “dystalgia,” a wash of despair that one’s life has been futile.

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.

“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.”

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?”

“It is joy to be hidden,” the British psychoanalyst D. W. Winnicott wrote, “but disaster not to be found.”

“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.”