Strangers to Ourselves (Part Two)

Naomi is a black woman from Minnesota who threw her two children and herself off of a bridge in a suicide attempt in 2003. She and one of her children were rescued, but the other child drowned. Naomi was convicted of manslaughter and spent sixteen years in prison. This is a story of race, class, marginalization, psychosis.

Aviv provides plenty of family and socio-cultural background for a deep understanding of the contexts within which Naomi’s mental health assessment and treatment approaches impacted Naomi, but also highlights the types of biases that are likely built into our mental health and criminal justice systems.

Naomi was caught in a kind of double bind because her behavioral manifestations of psychosis also critiqued racial bias in society. Her delusions seemed to contain social-cultural truths. Aviv explains that “Minnesota determines whether a defendant qualifies as insane by using the M’Naughten Rule, a standard established in the United Kingdom in 1843, that requires that ‘the accused was laboring under such a defect or reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know that what he was doing was wrong.” (p.148) “When Naomi was evaluated at the Minnesota Security Hospital, two doctors concluded that she did not meet the requirements for the M’Naughten defense. Her delusions, they noted, stemmed from astute observations about the society in which she lived. She told the doctors, ‘when the framers of the Constitution were signing the document, they told a Black person, ‘Hey nigger, go get a pen’. On the bridge she said she had felt terrified for her children, because she knew ‘their life would be filled with inferiority, indifference, and ridicule.’ She explained that ‘I did not want them to die. I just wanted them to live better.'” (p.149)

Aviv says, “the evaluators seemed distracted by the truth of her sociological insights. Delusions are not spun from pure fantasy. It would be impossible to separate Bapu’s desire to wed Krishna from her dismay over the way that wives in traditional Indian households were treated; or Ray’s obsession with avenging his failed life and career, his fall from grace, from his expectation that white educated men should not have to contend with such a fate. Naomi’s psychosis drew from reality, too, but her doctors seemed to expect that delusions couldn’t on some level make sense.” (p.150)

The role that race and class may play in psychotic experiences is rarely considered. Revisiting my proposed systems approach to understanding the etiology of schizophrenia, as described in my post, “Back to Schizophrenia Part III”, the diathesis-stress model, which may take the form of genetic, psychological, biological, and situational factors which set up predispositional vulnerabilities, I would add race, class and gender as possible factors. So, in addition to other predispositional vulnerabilities, Naomi was a poor, Black woman.

Aviv says, “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 ‘a useful place of healing for African Americans’ 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.” (p.130) Aviv says that “Black Americans are systematically underrated for pain, as compared with white patients” and “Their suffering is naturalized, as if they were built for it, a myth with a long history in this country.” She quotes Helen Hansen, a psychiatrist/anthropologist at UCLA, ‘it is woven into the fabric this country that Black womens’ role is to do the work, to do the suffering, so why would we-the mainstream mental-health field-be chasing them down and asking, Can I treat you for your sadness.'”(pgs.130-131)

Aviv also discusses the historical “idea that emancipation damaged the Black psyche”. “Like the Parisis, the group of Indians thought to have assimilated British colonialism too abruptly, their minds, it was said, were buckling under the shock of transition” (p.136) This self-serving notion obviously presumes that Black people can’t handle being freed and civilized too quickly.

For Naomi, the interplay between social-cultural biases and individual personal suffering created a kind of dead end and escaping with her children by jumping off a bridge seemed her only option.

Laura has a very different background from Naomi. She grew up in a wealthy Greenwich, Connecticut community. She was a high performer in everything she engaged in. Laura had been diagnosed with Bi-polar Personality Disorder and then Borderline Personality Disorder. She was medicated for both of these. At one point Laura was prescribed Naltrexone to block the craving for alcohol, but she was also already taking Effexor (an antidepressant), Lamacal, Seroquel, Amblify, Ativan, Lithium, and Synthroid, a medication to treat hyperthyroidism, a side effect of Lithium. One of the central issues in Aviv’s report about Laura is the possible distinction between a “medicated self” and a “baseline self” (if there is such a thing). Laura was so sedated that she was sleeping fourteen hours a day and feeling dis-connected from what she felt was her “real self ” so she decided to “de-medicate”. Aviv discusses this along with her own continuing use of Lexipro. Laura has continued to manage her symptoms without medication , while Aviv manages her own with the aid of Lexipro.

From the research I have been reading there is no one-size-fits-all approach to medicating or not medicating for various mental illnesses. I personally question whether we can realistically identify a so-called “baseline self”, though most sources do describe what a “medicated self” experience is like. Laura was obviously over-medicated and felt disconnected from her previously non-medicated self. There are certain medications, such as Lithium, which have, in the past, been over prescribed and even abused. It is well known that Lithium was widely used in mental institutions, ostensively to mute symptoms, but to essentially manage and control patients by pacifying them. Yet there is a danger in not judiciously using helpful medications, along with psychotherapy to ameliorate serious mental illnesses.

Hava was the young teen who Aviv had formed an attachment to when she was in the hospital at age 6 for anorexia. As an “Afterword”, Aviv tracks down Hava’s father only to find that Hava had recently died. Aviv uses this afterward to tell more of Hava’s story and to return to her own reflections about anorexia. Aviv learned from Hava’s journals and from her father, David, that Hava had been hospitalized multiple times and was even in a coma after a suicide attempt. She had essentially run out of money and options and ended up living with her father, who was a physician, for twelve years. Hava wrote “I suppose I am one of those people that thoroughly understands myself yet I am a stranger to myself”. (p.233)This nuanced reflection, from which Aviv gets the title of her book, highlights the complicated experiences of identity and mental illness, which Aviv has so astutely represented throughout her book. In puzzling over what may have distinguished Aviv from Hava in how anorexia affected them, Aviv refers to what Louise Gluck, who was anorexic, wrote: “‘The tragedy of anorexia seems to me that its intent is not self destructive, though its outcome often is. Its intent is to construct, in the only way possible when means are so limited, a plausible self'” So Hava constructed her “plausible self” as the dependent anorexic, while Aviv says, “on these terms, perhaps my experience with the illness could be viewed as a success. After I left the hospital, my parents were a little afraid of me. They deferred to my opinions, and everyone established clearer boundaries. At the same time I was given latitude to behave as oddly as I pleased. I never felt stuck in a particular story that others had created for me. I had the freedom to get bored of my behavior and to move on.” (pgs. 229-230) I suspect there is more to the reasons the outcomes for Hava and Aviv have been so different, but their age differences while in the hospital and the ways their significant parental figures treated them once they were released must have played an important role.

One of the beauties of Aviv’s book is that there is no easy summary of the stories she has told or issues she has raised. We are currently burdened by an avalanche of psychological diagnostic and self-help literature , most with attempts to simplify and offer solutions for various mental illnesses. My own research indicates the tangled web of personal, social, cultural, institutional, medical contexts within which we must all navigate in identifying and working through mental disturbances. Rachel Aviv illuminates this tangled web.

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