Shortly after her sixth birthday, Rachel Aviv stopped eating. It had been Yom Kippur the week before, and members of her family had observed the traditional fast. Back at school, thrumming with leftover “religious energy”, she refused even the tiny portions her teacher put on her plate. “She looked at me carefully – I could feel her contemplating who I was, and her focus was exhilarating,” Aviv remembers.
She persisted through dizzy spells and dehydration, and in short order she was admitted to the Children’s Hospital of Michigan for “failure to eat”. In the anorexia unit, the threat of the “feeding tube” hung over every meal – though in her childlike imagination, this became a terrifying, Willy Wonka-esque device: “a huge tube, like a covered slide, that I would live inside”.
There were older girls in the unit, among them Hava, 12. Beguiling and charismatic, she inducted newcomers into the rituals of calorie counting and exercise. Aviv was monitored by the nurses for 45 minutes after she ate, to make sure she didn’t throw up. Until that point she hadn’t even realised that it was possible to vomit voluntarily.
Two weeks in, she unexpectedly found herself finishing a meal without realising it, and was allowed to call her parents as a reward. The spell was broken, although to her it felt like “a random choice”. Despite this, the unit’s psychologist recommended she be sent to a psychiatric hospital for the next phase of her treatment. Aviv’s mother refused, and her illness never returned.
The “Sliding Doors” story that opens this profoundly intelligent book – Aviv says she was “recruited for anorexia, but the illness never became a ‘career’” – suggests that what will follow is a stark repudiation of the medical model that nearly claimed her, a warning about the dangers of overdiagnosis, a sceptical take on illness as identity. That she avoids these easy positions is testament to the open, curious nature of her inquiry. If there is an argument she wants to advance, it is that the stories we tell about distress, and unusual, sometimes destructive behaviour, are just that – stories. They can be salvational, oppressive, or something in between; they can work primarily for our benefit, or for others. They can also, in the same person, change or intermingle. Beyond them lies something elusive: the initial thoughts and feelings, “when a person’s angst and loneliness and disorientation had yet to be given a name and a vessel”. Aviv’s brush with not-quite-anorexia has allowed her to keep in touch with this inchoate mindset, and so she finds herself “searching for the gap between people’s experiences and the stories that organize their suffering, sometimes defining the course of their lives”.
That search results in a set of superbly written portraits of five people who sit at the crossroads of alternative explanations for their pain. Starting in the 1970s, there is Ray, who embodies the clash between psychoanalysis and psychopharmacology. A highly driven physician turned businessman, his wife and sons leave him after years of being ignored. Locked in a doom-loop of regret and increasingly unable to function, he is persuaded to check into a mental institution. But at Chestnut Lodge, Maryland, only talking is on the menu. His doctor prescribes a rigorous schedule of therapy and proclaims that if Ray were to “stay in treatment for five or 10 years, he may get a good result out of it”. Drug treatment, on the other hand, “might bring about some symptomatic relief, but it isn’t going to be anything solid [after] which he can say ‘Hey, I’m a better man, I can tolerate feelings.’”
Ray develops a certain amount of insight, even adopting psychoanalytic language: he exclaims in his journal “I’m lying midway between Eros and Thanatos”, writing that he feels as if “a mirror was being held up to me”. But the process is slow and gruelling. Frustrated, his mother has him transferred to Silver Hill, where antidepressants are the order of the day. After three weeks, he experiences a breakthrough: “Something is happening to me” he tells his nurse. For the first time he feels real sadness over the loss of his family. Gradually, his sense of humour and interest in his hobbies return. He is discharged after three months and decides to sue Chestnut Lodge for malpractice. The resulting case is billed as the “Roe v Wade of psychiatry”.
Then there is Bapu, the Indian woman who stands on the cusp of mysticism and delusion. After marriage into a hostile family, she turns to religion to salve her loneliness, praying several hours a day in the only space in the house she can call her own, essentially a tiny cupboard. The 16th-century poet Mirabai, who turned her back on husband and family, believing she was married to Lord Krishna, becomes her role model. Bapu runs away to a temple, only to be found and sent to a mental hospital.
There is the deeply affecting story of Naomi, whose madness might be chalked up as a rational reaction to an unremittingly racist world. An African American woman from Chicago, she survives a childhood of extreme deprivation only to be harried by a constant sense of persecution and hatred. In 2003, terrified that the end of the world is imminent and she and her family are about to be rounded up and killed as “undesirables”, she jumps off a bridge with her two children in her arms. One of them dies. Juries in that part of the world almost always reject insanity defences, and Naomi is sent to jail for 15 years.
There is Laura, who comes closest to what you might call psychiatric-patient-as-lifestyle-choice. She is an overachiever from gilded Greenwich, Connecticut, whose illness occasionally offers her a break from the high expectations of her milieu. Medication serves to keep her at the top of her game: Harvard student, varsity squash player. At this point, Aviv inserts the story of her own midlife re-entry into the orbit of psychiatry. After a bout of anxiety, she is prescribed Lexapro for six months. Six months turns into 10 years, during which she repeatedly tries to come off the antidepressant, but feels less herself – or less the sociable, spontaneous self the drug had allowed her to inhabit. She discovers that “to continue as the person I’d become I needed a drug”. We return to Laura, who finds herself the victim of a “prescription cascade”, with new pills added to treat the side-effects of the old ones. Eventually she decides she’s had enough, becoming an online evangelist for pharmacological abstinence. Aviv, meanwhile, makes an uneasy peace with her augmented personality.
None of these narratives offer simple answers. Antidepressants don’t solve all of Ray’s problems, and his regrets and self-obsession pursue him to his grave. Bapu is not some holy woman colonised by an alien psychiatric tradition: as her daughter says after visiting her room at Guruvayur Temple, its wall covered in incomprehensible scrawls: “the person I saw – that was not a spiritual person. That was a person who was quite lost.” Naomi is not merely a victim of structural oppression, an analysis that risks becoming “another iteration of dismissing individual accounts of black people’s pain”. And the vehemently anti-drug stance assumed by Laura after she tapers off every last pill is, Aviv argues, merely another way of making medication the be-all-and-end-all of conversations about mental health.
What about Hava? By the time Aviv looks up her former hospital buddy, it is too late. Dogged by chronic eating disorders, she had died in her sleep in her mid-40s, only a few weeks earlier. Despite everything, she’d found happiness with a loving partner, and kept a lively, insightful journal for many years. This is something Hava had in common with each of the other characters, and is what allows Aviv to craft such subtle biographies. It also makes a crucial point for her: despite the rival camps and competing explanations, the riddle of mental illness is not so hard – its causes are “an interplay between biological, genetic, psychological, and environmental factors”. But it can be unfathomably complex as it plays out in people’s lives. Ultimately, as Aviv’s remarkable book shows, only their own stories can make sense of it.
• Strangers to Ourselves by Rachel Aviv is published by Harvill Secker (£18.99). To support the Guardian and the Observer buy a copy at guardianbookshop.com. Delivery charges may apply.
