Rachel Aviv's Strangers to Ourselves is in many ways an extraordinary book. On the surface, it presents case studies on mental illness, interwoven with her own experience of anorexia nervosa. The book opens with a prologue describing Aviv's time as an in-patient on an eating disorders unit when she was aged just 6 years old, and ends with an epilogue devoted to a fellow patient (Hava), who Aviv met on the same unit many years before. Contrasts between their subsequent lives, and in their mental health outcomes, are sensitively woven through the book, hovering on the horizon, and movingly revealed in the epilogue.
The book's strength lies in the engrossing way in which it reveals the complexity of mental distress, the impact of diagnosis and treatment on the individual, and in illuminating often incomprehensible experiences lived through by the featured protagonists. Each detailed account features a range of viewpoints and evidence, layered carefully, that connect slowly like a 1000 piece puzzle. This is achieved via detailed, empathic and sensitive research by the author, who deep-dives like a curious detective into the lives of Ray, Bapu, Naomi, Laura and Hava. At the end of each chapter, I felt I knew them all personally, and deeply.
Aviv shares much of her own experience, and her careful negotiation with the friends, family, clinical and support staff of those featured is evident. It is clear that these relationships have been developed over time and provide opportunities to fact-check and reflect. The investment in these relationships, and the commitment to the truth of each story, provide nuanced insights into the experiences, lives and concerns of those under scrutiny. At times these challenge what we understand by mental health, mental distress and mental illness, but in a gentle and perceptive way. I sensed an unspoken contrast with the regulated and pressured settings that staff often operate within, and the formulaic, outcome focused methods that have become commonplace in mental healthcare.
The importance of history and context underpin the scrutiny of individuals that is presented. The history of psychiatry is never far away; in the evolving diagnostic categories in the DSM, the battle between psychoanalytic and biological factions, the rise of psychoactive medications and the role of insurance companies (in the USA).
The role of culture and different healing practices is also explored, for example in the case of Bapu, a married Indian woman, with two children and a devotee of the Hindu god Krishna. Bapu was diagnosed with schizophrenia and repeatedly left the family home to travel to temples on a quest to fulfil her devotion, eventually becoming destitute and homeless. She endured brutal psychiatric treatment including being chained to the bars of a cell in Kilpauk Mental Hospital, administered antipsychotics and given electroconvulsive therapy, which was then a standard treatment for a range of conditions in India, often performed without anaesthetic or muscle relaxants. Bapu chronicled her experiences in many journals that provides rich experiential material so that she feels present within the story even though she is deceased. Here it becomes clear that Bapu was aware of the fine balance between her religious devotion and mental instability. In an unexpected twist, towards the end of her life Bapu was recognised in her community as a healer with special powers that gives credence to some of her previously misunderstood and sanctioned beliefs and behaviours. Aviv deftly weaves in the influence of such experiences on the wider family, as her son Karthik and daughter Bhargavi reflect on Bapu's life, and their own life choices. Thus, the book provides further evidence of the perpetuating consequences of mental health problems, in our own lives and in the lives of those around us.
Strangers to Ourselves reveals how biopsychosocial factors combine and manifest differently, how individuals exercise agency idiosyncratically, and dare I say, how fate intervenes and psychical experiences present in ways that cannot fully be understood. And I was reminded that recovery is a fluid concept, and ultimately uncertain.
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