How Mental Illness Shapes Our Identities

Not long after her sixth birthday, Rachel Aviv stopped eating. Her family had just celebrated Yom Kippur, the day of atonement, and it suddenly occurred to her: She could say no to food. Maybe it was a response to her parents’ custody battle, maybe there was a sense of pride in her self-restraint—Aviv’s memories, and her medical records, are unclear. Her doctors, though, were certain she had anorexia, and promptly moved her to a hospital ward alongside girls twice her age.

Her family could only visit if Aviv ate her meals, and, once she did, a spell was broken; soon enough, she’d gained some weight and was sent back to first grade. But the experience left Aviv with an enduring interest in the earliest phases of mental illness, when, as she writes in her book Strangers to Ourselves, “a condition is consuming and debilitating but has not yet remade a person’s identity and social world.” She wants to know how the stories we tell about mental illnesses can carve out their course. After all, she says, “there are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.”

Aviv, who is now a staff writer at The New Yorker, divides her book into a series of profiles of “unsettled minds,” including Laura, an affluent Harvard graduate whose bipolar disorder becomes something of a career; Bapu, a Brahmin mother of two who trades domestic life for consuming devotion to a deity; and Naomi, whose psychosis is hard to untangle from the very real racial injustice around her. Here, Aviv discusses the limits of psychiatric insight, the challenge of pinning down your true self and the power of a community.

Image: Kristina Dittmar

You write about what philosopher Ian Hacking calls the “looping effect”: a diagnosis can become a self-fulfilling prophecy as people adjust their behaviour to fit their illness. Did your age at the time of your diagnosis disrupt that loop?

That diagnosis meant nothing to me. Anorexia sounded like this big, fancy word, but it had no resonance. It wasn’t ever used in my peer group. I left the hospital and it was a discrete experience that I saw as sort of this freak moment. I think because I was so young, it just didn’t solidify as the problem with my life. I didn’t have insight. I had no idea why I had done that. And I think I was allowed a degree of: well, six-year-olds don’t have much power over anything in their lives. But one thing they do have power over is what they put in their mouth. That very simple, spare explanation was allowed to be it.

That notion of insight comes up again and again in the book. How does the medical profession understand insight?

There are two different ways of thinking about insight. One is more the psychoanalytic approach: If you have an awareness of what’s causing your suffering or sort of family dynamics produced your sense of self, then you can have this epiphany, and that epiphany itself can be healing. That was the model 40, 50 years ago. And then, over time, what psychiatrists seek for patients to understand in the quick clinical encounter is more like: I have the insight to realize that my brain is not properly functioning, because I have a chemical imbalance and I need to take medications to help.

What context is missing from that model?

There’s one extreme, which is to assume that having insight into the dynamics that cause an illness is going to be healing. Then there’s the other extreme, which is that we’re not even going to try to engage with the context of the family, the upbringing, the community, the ways all sorts of social and economic and political factors might have shaped your sense of being in crisis. Someone like Naomi, who I write about in the book, is very aware of the ways that discrimination, poverty, violence and death have shaped her life. And then to have a doctor say, all I want you to do here is acknowledge that you have a mental illness and you can help yourself if you take medications, it can feel really invalidating.

Is there something compelling about a biomedical explanation for mental illness, though? Does it offer a sense of neutrality?

Yeah, and it does this powerful thing of taking away parents’ sense of being at fault, or people blaming themselves. I think it’s interesting that it’s always assumed the biomedical explanation will reduce stigma, and that hasn’t borne out. There’s a whole other set of stigmatized connotations that come from having this permanent biological illness—that it’s in your bones, it’s in your body, and it’s going to mark you for life.

How can certain illnesses or medications get gendered? I’m thinking of borderline personality disorder diagnosed more often in women, or prescriptions for an SSRI like Lexapro, which your friend memorably described as a pill “to make the ambitious ladies more tolerable.”

Pharmaceutical marketing campaigns are so interesting. Recently, white women are shown with a ring on their finger, the kids in one hand, their briefcase in the other. And the drugs are celebrated as the thing that will allow them to have their full working life and their full motherhood. But a common side effect for SSRIs is to take away people’s sex drives. It’s interesting that we expect a lot of working mothers, but sexuality is not one of them. SSRIs have been widely accepted without much conversation about what it does to sexuality.

And there hasn’t been much conversation about—or even much research on—people who try to come off those medications, either. You write about your own struggles to come off Lexapro.

I think seeing what happens when people go off their medications doesn’t feel sexy and exciting as a research project. I also think there’s some level of paternalistic thinking—we don’t want to study the difficulties that people have getting off medications, because we’re scared if we publicize it, people won’t get on the medications. But that takes the decision out of people’s hands.

Could that also be influenced by the idea, as we’ve moved to a biomedical explanation for mental illness, that if this illness is chronic, we don’t need to study the off-ramps for medication?

Right—that if you are taking medication for a chemical imbalance, you’re always going to have a chemical imbalance, and you’re always going to need to fix it. So there’s this sense of rewriting what your baseline is, as opposed to seeing mental health as something that ebbs and flows. Maybe you go through a hard phase and take that medication until you’re in a better place.

How do we know what our baseline is?

That’s something I’ve struggled with. I went on Lexapro in my late 20s. I was an adult, but I don’t know, maybe I hadn’t grown into my true self yet; your sense of self is always shifting. But if Lexapro allows me to interact with friends and family in a more loving and open and warm way, there’s something sad about me saying, well, that’s not my baseline self—my baseline self is more rigid and inhibited. I don’t like that idea.

There are ways our sense of self shifts as we get older, adding careers and families, but also as we navigate external events that act upon us. I feel the pandemic must have changed my baseline self.

It’s interesting that, in the wake of the pandemic, people have called it a mental health epidemic. You could phrase it that way. But you could also phrase it as people responding to the grief and loneliness of the conditions of their lives. I think loneliness in the culture is talked about more, but I don’t know that’s it’s become more of a focus for psychiatry yet.

Yet all the people in your book found value and help in speaking with someone—in alleviating their loneliness.

One of the things I was struck by with all the people I wrote about was how they felt seen by someone who had gone through a similar mental illness, or even someone who could understand how they were processing their illness. I think psychiatry generally thinks about people as individual brains with individual problems, and not as much about the ways in which problems emerge in the relation between a person’s brain and their community. And then so too does recovery.

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