Strangers to Ourselves:Unsettled Minds and the Stories that Made Us (2022) – Rachel Aviv (Review)

Rachel Aviv’s new book is about mental illness and all the messy notions of stigma, the impact of race, cultural prejudices about women, and psychoanalytic vs medicalized psychiatry. Aviv comes close to what my blog is all about: the relationship between psychotherapy and culture. I may be returning to some of her chapters after this post since she has covered some of the ground I covered in my research in India and with the Washington School of Interpersonal Psychoanalysis practiced at Chestnut Lodge by Harry Stack Sullivan, Freida Fromm-Reichman, and Otto Will (I wrote about this in my post “Back to Schizophrenia”).

Aviv tells the stories of five individuals, Ray, Bapu, Naomi, Laura, and Hava, in addition to herself, each of whom has a different set of diagnosed mental illnesses and through each, Aviv explores various critical social, cultural, medical, ethical issues.

Aviv approaches her research much as an anthropologist would, by spending time within social and cultural contexts of the protagonists of her stories. Her work is in the mold of Katherine Boo’s “Behind the Beautiful Forevers” (about slum life in Mumbai) and Anne Fadiman’s “When the Spirit Catches you, You Fall Down.” (about a Hmong family and their interface with the health care system in Merced, California), both of which I have used in ethnography courses because of their brilliant ethnographic research but also their engaging story telling.

Aviv begins with the story of herself being diagnosed with anorexia and briefly hospitalized at the age of six. The issue of how anyone could have anorexia at age six opens into an inquiry of the entire diagnostic enterprise in psychotherapy. She questions whether she had anorexia, though she had refused to eat for enough time to frighten her parents and psychiatrists. This experience acts as stimulus for her ongoing inquiry into what constitutes mental disturbance and how does the psychiatric and psychotherapeutic profession identify, diagnose and treat mental illnesses. What is the interplay between cultural context and situation and mental illness?

Aviv states in her introduction “At times I contemplated devoting the entire book to each life I have written about here, but I wanted to emphasize the diversity of experiences of mental illness, the fact that, when questions are examined from different angels, the answers continually change.” (p.25). This approach distinguishes Aviv’s book from most of the current literature in the mental health field. Though she devotes a chapter to each of the people’s stories, these individual stories provide avenues for Aviv’s investigation of the various complicated issues around the entire mental health enterprise. She summarizes what each story investigates:

” The book begins by telling the story of a man torn between the twentieth century’s dominant explanations for mental distress – the psychodynamic and the biochemical. The rest of the chapters move beyond these two prevailing frameworks: one character tries to understand who she is in relation to her guru and gods; another is reckoning with her country’s racist history and how it has shaped her mind; a third has been so defined by psychiatric concepts that she doesn’t know how to explain her suffering on its own terms.” (p.26)

I will summarize the issues as Avivi has presented them via each person’s story and comment on these issues.

Ray is a man who was diagnosed with melancholia or depression. After years of mostly psychoanalytic treatment at Chestnut Lodge, which was in Rockville, Maryland, Ray sued the establishment in 1982 for failure to cure him. Aviv’s reporting about the history of Chestnut Lodge and the psychoanalytic approach of Harry Stack-Sullivan, Freida Fromm-Reichman, and other psychiatrists at Chestnut Lodge is fair and accurate, yet she accepts uncritically the review from Thomas McGlashan’s 1984 meta analysis of case records from Chestnut Lodge, wherein he judged that psychotherapy was ineffective for schizophrenia. He famously stated, “the data are in and the experiment failed.” I challenged this assessment in my post on “Back to Schizophrenia”. McGlashan’s own commitment to the use of psychiatric medications, no doubt influenced his interpretation of the cases he studied. Also, it has always been extremely difficult to judge the relative success of psychoanalytic treatments, since they involve profound unsettling changes and possible personality transformations. As I reported in my earlier post, the treatment approach at Chestnut Lodge was distinct from most other treatment facilities in that people with psychotic symptoms were treated humanely, with respect. Psychoanalysts at Chestnut Lodge believed that listening to patients’ struggles and concerns and helping them navigate their ways of interpreting their being in the world would be more effective than alternative approaches, particularly using psychopharmaceuticals, which until settling Ray’s lawsuit, were rarely used. After years at Chestnut Lodge, Ray left and began a treatment process with psychiatric medications. He claimed that these medications worked for him, while the psychoanalytic treatment at Chestnut Lodge did not. I suspect that he was helped by his treatment at Chestnut Lodge, but because of narcissistic behavior patterns, he did not acknowledge how he was helped and needed to blame someone for his ongoing depression and inability to form healthy relationships. Perhaps these issues would have been better resolved had he stayed in treatment at Chestnut Lodge. As a result of this lawsuit, the psychiatrists at Chestnut Lodge were forced to begin using anti-psychotic medications. While Ray seemed to improve in some respects as a result of his medications, he continued to manifest obvious symptoms of depression, loneliness, anger towards his father, inability to maintain healthy relationships with others, and aspects of narcissistic personality disorder (not mentioned by Aviv). He could not stop blaming his time at Chestnut Lodge for all of his behavior problems.

Bapu was a woman from Chennai, India. Her story, as related by Aviv, involves a parental matched marriage to an older man, her life as the equivalent of a servant among her In-laws, Bapu’s alienation from her in-laws, her repeated running away to become a spiritual follower of various ashram gurus, and her mental health diagnosis of schizophrenia and hospitalization to attempt a “cure”. The topics explored in Bapu’s story include the relationship between spiritual/mystical experiences and those of psychosis; the role of women and marriage in India; how madness or mental illness is dealt with in India.

I interviewed two psychiatrists, two psychologists and a psychoanalyst, during a research trip to India in February, 2003. Among several themes each therapist mentioned in common is the custom of patrilocal (a wife living with her husband’s relatives upon marriage) arrangement along with a dowry system (the opposite of bride price, where a wife’s family must compensate in money or goods the husband’s family). These two practices put enormous pressure on a bride’s family and on the bride. Bapu’s case was a bit unique because she had her own house upon marriage and her in-laws came to live in her house. But she was nevertheless a stranger in her own house. Her husband and his relatives relegated her to the equivalent of a domestic servant. One of the most common complaints of female therapy patients in India (according to my interviewees) has been conflict between young wives and their mothers-in-law. Because of the patrilocal system new wives are expected to serve at the will of their mothers-in-law, typically in the mother-in-law’s house. It is not uncommon for new wives to run away. It is possible that part of Bapu’s reason for repeatedly running away and either taking up residence at various ashrams or temples, or in homeless situations, under the assumed rationale of seeking spiritual transformation, was to escape the oppression of her in-laws. Seeking some kind of spiritual existence in a culture of gods, demons and mystics may be interpreted as a symptom of a form of psychosis, such as schizophrenia. Hallucinations and delusions being symptoms of schizophrenia, are typically manifested by mystics who have been spoken to or commanded by a god or gods. Delusions of grandeur and paranoia, and hearing the voice of God are regularly associated with religious mystics – even leaders of mainstream religions (e.g. Jesus, Moses, Joseph Smith, etc.). Aviv quotes one psychiatrist, Dr. Manon (who I also interviewed), who said, “In schizophrenia too much religion is not good” (p.79). I believe she meant that people with a preconditional vulnerability to schizophrenia would have too much cultural reinforcement for being swallowed into spiritual delusions and thereby magnifying their symptoms. Aviv seems to question this, but I think Manon had already had plenty of experience with psychotic patients and her own cultural patterns to identify this phenomenon.

Russell Shorto, in “Saints and Madmen” (1999), discussed the possible similarities and differences between psychosis and mysticism. He quotes Tony Stern, a Martin Buber scholar: “I think there is a fine line between the two conditions, and perhaps the underlying process is the same- so that essentially the question is what do you do with it, how you respond to it. If you look at the great mystics, I can’t think of one who did not show signs of what today would be considered severe psychosis or manic-depressive illness.” (p. 97). Shorto also refers to a distinction made by Tomas Agosin: the psychotic delusion is grandiosity; “a mystic is humbled by his experience, a psychotic inflated” (p.71). From Aviv’s description of what Bapu communicated in her journals and the fact that Bapu became more like a holy person (as perceived by her community) in her later years, I think she was humbled and not inflated by her experiences.

Aviv suggests that psychoanalysis may not be a good fit for Indian culture and she mentions the original contact that Freud had with Girindrapekhar Bose (though she does not provide his name), the founder of the first psychoanalytic society in Calcutta, India. Aviv does not dive deeply enough into this topic and she almost brushes it aside by stating, “But Freud’s psychoanalysis proved largely incompatible with a culture for which mysticism is often essential to people’s lives.” (p.80) Bose actually developed a theory and practice which paralleled that of Freud, but without ever meeting Freud or reading his books. He contacted Freud via letter once he had read some of Freud’s books. Freud was thrilled that he had a devotee in India. This is well reported in Ashis Nandy’s book, “The Savage Freud” (1995). Nandy (who I interviewed in 2003) is known as a political psychologist and some of his analysis points to the influence of colonialism. He said, “Psychoanalysis came to represent something more than a therapeutic technique that could be adapted to the mental health problems of the burgeoning, partly decultured, urban bourgeoisie, even though that is how Bose often viewed it, especially when writing for his international audience. Psychoanalysis also had to serve as a new instrument of social criticism, as a means of demystifying aspects of Indian culture that seemed anachronistic or pathological to the articulate middle classes, and as a dissenting western school of thought that could be turned against the West itself. ” (p.83). Nandy says that his essay about Bose tells how “Bose’s unique response to Freud’s theories was shaped by the psychological contradictions that had arisen in Indian culture due to this colonial impact and the cultural contradictions within psychoanalysis itself” (p.83). So while Aviv may be somewhat correct about psychoanalysis being largely incompatible with a culture still imbedded in mysticism, she has not considered the ongoing influence of Western culture in general and Western theories and methods of healing.

Sudhir Kakar, India’s foremost psychoanalyst, whom I interviewed in 2003, spent three years as an ethnographer investigating the many and varied approaches to healing mental illness among India’s traditional healers and those with various emotional, mental illnesses.The results of his research are reported in his book, “Shamans, Mystics, and Doctors: Psychological Inquiry into India and its Healing Traditions.”(2002). As a trained psychoanalyst with a practice in Delhi, Kakar is able to compare Western and traditional Indian approaches to healing mental illness. Kakar states, “what makes the majority of Indian approaches to mental health different from the dominant Western view on the subject is their emphasis on the relational. In the Indian prescriptive lists (for example in Ayruveda) one is struck by the number of ideals of mental health that prescribe the person’s behavior in relation to others, especially family and community. A restoration of the lost harmony between the person and his group, we saw earlier, was one of the primary aims of the healing endeavors in the local and folks traditions.” (p.274). Kakar mentions a number of other distinctions between Western psychotherapy and traditional Indian approaches to mental health, and though his book is more than twenty years old, most of what he identified as differences are still in evidence while Western influenced psychotherapies continue to exist alongside traditional practices. I will revisit this topic in a future post.

I will continue my reflections on Aviv’s book in the next post.