State of Mind

From Diagnosis to Destiny

Rachel Aviv’s Strangers to Ourselves examines how the stories we tell about mental illness shape our experience of it.

A white book cover that says "Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, Rachel Aviv." The book stands against a blue background.
Photo illustration by Slate. Photos by Getty Images Plus and Macmillan.

Welcome to State of Mind, a new section from Slate and Arizona State University dedicated to exploring mental health. Follow us on Twitter.

On Oct. 13 at 1 p.m. Eastern, join the New America Fellows Program and Future Tense to discuss Strangers to Ourselves: Unsettled Minds and the Stories That Make Us with author Rachel Aviv. RSVP here.

The first time I saw a psychiatrist I arrived with a diagnosis in mind: obsessive-compulsive disorder. A few weeks earlier, the therapist I was seeing—who was in training to complete her graduate work and offered free sessions at the university where I worked—had hinted at the possibility and suggested I see a doctor. This had come after I explained how I often had to build five or 10 minutes into my routine when I left the house, to allow for time to go back and check that I had turned off the shower and the oven, unplugged a straightening iron, and locked the door. I sometimes had to take photos of these things—the burner in the off position—to return to later in the day when I was struck by a feeling of dread that I had forgotten something.

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I found the therapist’s suggestion intoxicating, even liberating. I began Googling, and on the second or third page of results, buried under the more reputable, Mayo Clinic-esque pages, was a listicle titled “10 Signs You May Have OCD: When do personality quirks cross the line into obsessive-compulsive disorder?” I read the list once, twice, tallying my habits against a caricatured image of OCD.

OCD, I thought, made sense. It was a new narrative, a new organizing principle, around which to structure my life. It felt more specific than anxiety, the diagnosis I had built the previous three years around. Anxiety, I thought, was too nebulous: Everyone was anxious! Anxiety could mean so many things—and thus, I worried, too often meant nothing. I wanted a diagnosis, a word, an outline, that could reflect the gravity of the thoughts bouncing around in my head. Perhaps OCD was it.

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I returned to this experience as I read Rachel Aviv’s Strangers to Ourselves: Unsettled Minds and the Stories That Make Us. The book is a beautifully written, profoundly researched narrative, and each time I try to describe it to someone, I stumble over words until I finally land on “You just have to read it.” Aviv begins with the story of her own hospitalization, at age 6, for what doctors diagnosed as anorexia. Aviv spent six weeks in the anorexia unit. She now sees her time there and the period shortly after her release as a crossroads of sorts—after all, she writes, “At six years old, it still seemed possible that I could become someone else through sheer will.” In the unit, she began to imitate the older girls she met there (refusing to sit or lie down until bedtime, carefully tracking her weight in ounces, employing jumping jacks in idle moments). Had she stayed there and continued emulating them, her path could have been different.

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“This sense of narrow escape,” writes Aviv, “has made me attentive to the windows in the early phases of an illness, when a condition is consuming and disabling but has not yet remade a person’s identity and social world. Mental illnesses are often seen as chronic and intractable forces that take over our lives, but I wonder how much the stories we tell about them, especially in the beginning, can shape their course.”

Strangers to Ourselves is a book about Aviv’s experiences, but also the experiences of Hava, a companion from the anorexia unit who was forced down a different path. It is about Ray, a Virginia doctor caught in the tension between “biochemical” and “psychodynamic” explanations for mental illness, and it is about Bapu, an Indian woman whose psychiatric journey is shaped by her own relationship with religion, and others’ misunderstanding of it. It is about Naomi, a Black mother who carried a “grief that cannot be articulated” and “pain that had haunted her family for generations”: the sort of grief and pain that is misunderstood, denied, and exacerbated by a mostly white mental health system and the racism intertwined within it. And it is about Laura, who, as a college student, got trapped in a “prescription cascade” that erased any notion of her “baseline self.”

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It is about all of them, but their stories blend into something bigger. Aviv acknowledges the limitations of a case study approach to writing about mental illness, insofar as it “presents … a closed world, limited to one person and one explanation.” As someone who writes and edits articles about mental health, I too am wary of shared truths. Our stories unfold in unpredictable, tumbling ways. But when Aviv acknowledges “where and how people live, and the ways their identity becomes a reflection of how others see them,” she opens up that closed world. After all, she writes, “Our illnesses are not just contained in our skull but are also made and sustained by our relationships and communities.”

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Strangers to Ourselves, thus, is about identity: the way it is tangled up in our mental health systems and the cultural narratives about those systems—shifted and shaped and transformed by them. The shared truth we can walk away with is this: “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.”

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When I offered up OCD to the psychiatrist I saw, he shook his head. Instead, he re-diagnosed me with anxiety, and this time added on depression. He sent me home with a prescription for Lexapro, which I filled. I never saw him again, but I thought of him often. I tried to settle back in to my diagnosis of anxiety. Months passed. I never started Lexapro—first because I moved and wouldn’t have been able to do a follow-up, and then because things in my life slowly started to get easier. Still, I turned the pill bottle around in my hand, considering the paths it might point me down. Aviv recounts her own experience with Lexapro: a complicated one, charged with gendered cultural baggage. “I wish I had a more flexible approach toward my feelings of inadequacy,” she writes. “… but I also feel closer to that space of flexibility when I take Lexapro; it seems to relieve the cognitive rigidity that often accompanies anxiety and depression—the sense that one’s story can unfold only one way.”

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I started seeing a new therapist, who sent me a long series of diagnostic tests. These, she said, were to measure my progress. One, the GAD-7, was what the doctor at the student health clinic used to diagnose me when I first stumbled into her office at 19. The seven questions, which the respondent is asked to rate on a scale of “not at all” to “nearly every day,” echoed familiar: “Not being able to stop or control worrying,” “trouble relaxing,” “feeling afraid as if something awful might happen.”

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For years, I’ve used my anxiety diagnosis as a simple explanation for the way I feel and act. Diagnoses, ultimately, are lenses of language and logic through which to understand ourselves, to give meaning and order to feelings that we so often experience as chaotic and cruel. In that way, they open up a world of possibilities. In other ways, our diagnoses can limit that world—explanations for today’s experiences become predictions for tomorrow’s. It’s easy to feel trapped in a box of preordained futures.

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A few weeks ago, my therapist pulled up a report comparing my recent GAD-7 score to one from a year ago. My anxiety had gone down two points, she said proudly. I considered this, how a year of experiences and a universe of emotions could be boiled down to a 21-point scale. How this scale was a part of who I understand myself to be. As Aviv writes of Laura, who was diagnosed with bipolar disorder at age 14 and whose coming-of-age was marked by 19 different psychiatric drugs and four hospitalizations: “The diagnosis reflected her state of mind, but it also influenced her expectations for herself.”

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I asked my therapist if I would ever graduate from the GAD, if the “have” in “I have anxiety” could ever become “had.” Who would I be then? It was complicated, she explained. Aviv suggests that answering the question of why some “recover” from mental illness and others never do “requires paying more attention to the distance between the psychiatric models that explain illness and the stories through which people find meaning themselves.”

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Worn-out, generalized narratives of mental illness often make our own stories feel static. Perhaps it is only through sharing them that we realize they rarely are.

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State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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