October 22, 2022

I don’t quite know what to do with mental illness memoirs. I’m naturally interested in their subject, as I suffer from bipolar disorder myself. And they fulfil an important social function: despite the rise of innumerable online voices yelling about mental health and ableism, the reality of psychiatric illness remains unknown to most people. Personal narratives tell us things that medical literature doesn’t. The more stories we tell, the more we might expand our moral imagination for the sick.

And yet I worry, too. I worry because selling a book, especially for any kind of decent advance, is a tricky business, and the temptation to be prurient and sensationalist must be considerable. I am a committed enemy of romanticising mental illness, which contributes to the impression that the mentally ill are somehow living deeper, more “intense” lives, rather than more painful ones. I want mental health memoirists to understand their profound responsibility to tell the grubby, sad truth about this life.

But mostly, I envy people who write mental illness memoirs. I envy their memories. They can recall the details of their psychiatric histories; I often can’t. Years have passed, faster and faster, since the major incidents in the history of my condition. For important portions of that history, I was brutally depressed, or grindingly manic, or actively psychotic, conditions not conducive to the formation of lasting memories. I have spent 15 years on and off (though mostly off) memory-destroying medications, and have now been on them for five years straight. And for most of that time I was actively in denial, about all of it, to the point of believing at points that it wasn’t real. I did not tell my siblings, those I was always closest to, for more than a decade after my first diagnosis. Sometimes I’d assert that I was finally on the straight and narrow, finally cured — an assertion that always, always preceded the next ruinous crash.

Some things I remember like they were yesterday. Some I don’t remember at all. When I write about my own mental health history, I write in ellipses and at a Dutch angle — for aesthetics, yes, to satisfy my own standards as a writer, but also because to tell it otherwise would make me feel like a liar. I just don’t trust my memory of some details.

I have spotted a similar instinct in other mental health memoirs. Girl, Interrupted is imagistic and ruminative, much less a recounting of the day-by-day events of Susanna Kaysen’s commitment to McLean Hospital, and much more a series of pleasantly meandering meditations on the concept of sanity and the self. Kaysen also includes original forms and files from her hospital stay; George Scialabba’s brilliant and haunting How to be Depressed consists of little else.

And then there’s Strangers to Ourselves. It’s not a straightforward memoir but rather a collection of brief vignettes, or case studies, about mental illness, written by Rachel Aviv. Her own story opens the volume. She became anorexic as a six-year-old, barely literate, and mostly unable to define what was happening to her. Aviv leaves unsettled the question of whether she was “really” anorexic — her age and stated motives for not eating complicate the question — and instead contrasts her own condition with those of the older patients around her. By reproducing her own experience of mental illness, Aviv brings a little skin to the game in a text that’s mostly about telling other people’s stories for them.

More important, her personal history segues into Aviv setting the boundaries of her project. The book is about people whose “lives unfold in different eras and cultures, but they also share a setting: the psychic hinterlands, the outer edges of human experience, where language tends to fail”. She explains her holistic approach:

“the book draws not only from conversations with them but from their diaries, letters, unpublished memoirs, poems, and prayers… It’s impossible to go back in time and uncover what baseline feelings existed before a story was told — when a person’s angst and loneliness and disorientation had yet to be given a name and a vessel — but I find myself searching for the gap between people’s experiences and the stories that organise their suffering, sometimes defining the course of their lives.”

This is what I needed, from this book, up front: both information about how these individual stories were compiled and an acknowledgment that we all, as patients, construct truths with the raw material of memories that so often refuse to cohere, and therefore use the textual record to confirm and supplement our stories. In the opening section, she quotes her younger self as writing: “I had some thing that was a siknis its cald anexorea.” I was initially sceptical: it sounds like an adult writing the way they think a child would write. But Aviv later explains that she had dug out her childhood diary. I didn’t need her to do so to make her recollection of her illness more real; it just helps to know that the exact wording came from the page and not her memory.

Sometimes, texts are all there is to go on. Aviv can’t speak to some of her subjects, such as Ray, a depressive who has been dead for years. Instead, she pulls significantly from his unpublished memoir, which follows his decision to sue a psychiatric facility where he was committed. Ray struggled through psychoanalysis at Chestnut Lodge, where he lived in for long months, only to come later to feel that he had been fooled by a broken paradigm that forbade the use of antidepressants. As Aviv tells it, Ray’s psychiatrist seemed to think of such drugs as a shortcut rather than a cure, and therefore avoided their use.

Aviv tells Ray’s story both for its own sake and to consider the fundamental conflict in late 20th-century psychiatry. The Freudian assumption that all psychiatric conditions could be traced to discrete events in childhood, and cured through excavating these memories in psychoanalysis, dominated American psychiatry for decades. It led a lot of patients to endlessly recite early traumas, without much therapeutic gain. That approach was overtaken by an ascendant hope that new drugs could fix chemical imbalances in the brain and turn psychiatry into a medical field like any other. Now, we appear to have swung back the other way: decades of disappointments in psychopharmacology have inspired many to declare that “there’s no such thing as a chemical imbalance”, which has become an inescapable social media bromide.

What frustrates me is that people seem unable to accept that the interaction between the brain and the mind is extremely complex. That the simplistic not-enough-serotonin theory of depression appears to be wrong does not imply that all neurological explanations are off-limits. We don’t have to yaw constantly between “all brain” and “all mind” explanations. Aviv, thankfully, settles on no pat answers to these questions, instead, simply meditating on them via Ray’s strange story.

Likewise, she uses every case study to examine the nuances of some broader social or economic or political issue. There’s Bapu, a Brahmin-class Indian woman whose religious adherence straddles the line between faith and madness; her story considers the conflict between Western medicine and spiritualism. There’s Naomi, a young black mother whose deepening paranoia compels her to attempt to drown herself and her two young children; her story illustrates how entrenched racism complicates psychiatric care for people of colour. There’s Laura, an affluent young woman who starts taking a cocktail of medications at a young age and finds it very hard to stop; her narrative helps explore the thorny questions of how long patients should stay on drugs. It’s never advisable to draw too deeply from individual stories in analysing societal trends, but the connections Aviv draws to such trends give the book teeth, making it more than merely poignant.

The final section enables us to consider Aviv’s responsibility to her subjects and the difficulties of telling their stories. It focuses on Hava, an anorexic who Aviv encountered at a young age and whose life she sees as something of a road untraveled, given her own early struggles. Hava appeared to be making clear progress in her life, finding a steady boyfriend and planning for her future; sadly, years of making herself sick had damaged her body’s ability to regulate the reflex, and one night she choked on her own vomit in her sleep. She is one the three people profiled who were dead prior to the completion of the book, but Aviv’s deference to their own words makes their stories seem like memoirs all the same.

Perhaps it’s a sign of solipsism that this book often provoked me to wonder what Aviv would make of my story. I crave the simplicity of having my life printed out in black and white text; I also dread the inevitably reductive nature of such an exercise, and I’m scared of what someone else’s eyes might see in my narrative. For me personally, mysteries abound. I couldn’t possibly tell you the name of the doctor who diagnosed me as bipolar. At the time, I was not conscious in a conventional sense and everything that happened seemed to happen somewhere outside of me, people puttering around and talking in strange language I didn’t understand. There was an ER, there was a shot of haloperidol, and there was a stretch in a grey and muted psychiatric facility. Someone must have written my diagnosis down on a chart. Who that was is known only to God and, I imagine, to some mouldering file somewhere that I have absolutely no interest in digging up.

There are a lot of things I don’t understand about my own history. Worse, I can’t remember if the weight of years, mental illness and medication has simply obscured that knowledge, or if I never knew. In general, my time in the mental health system has been marked by constant confusion; I would feel like a liar if I said, “and then this month, in 2011, this happened”.

Do the subjects in Strangers to Ourselves struggle the same way? What must it feel like, for those who are still living, to read this book? Aviv tends to avoid the overly literal, rescuing the book from questions of simple authenticity and making it, usefully, a record of how foggy our recollections can be. But I can also imagine readers who might be frustrated by the lack of clear lines between certain truth and imperfect memory. All of us long for order in the stories we read. I think that’s why people gravitate towards mental illness narratives, to clarify something that has been obscured by instability. But how do you faithfully translate what is by its nature not translatable?

I honestly don’t think writers tell lies in mental illness memoirs. I wouldn’t even say they bend the truth. I would suggest, perhaps, that they take the fragments of what they know happened, and through them assert a kind of truth, as part of a therapeutic process. That asserted truth might not look exactly like that of a dispassionate observer — say, one of the many doctors who wander into our lives, speak to us condescendingly, make marks on a chart, and shuffle out of our story. But I can’t see much harm done, when patients tell it themselves. The conceit of a memoir is that other people will be entertained by our misfortune; so long as we tell our stories with integrity, those who suffer through the instability and boredom and deprivation of dignity common to serious mental illness are entitled to our own frames. I only hope that both writers and readers know that the attempt to organise the experience is quixotic and we are narrativising the un-narrativisable. I understand the feeling that we must try anyway.

Aviv, like me, is wary of the way that definition can trap and limit us. In our online culture of mental illness, diagnoses are celebrated: young people wield them like talismans for a sense of validation. And I am not entirely a stranger to the seductive power of becoming one’s diagnosis, letting it become the load-bearing element of your personality. But I am also no stranger to the way that, further down the road, that self-definition becomes cramped and uncomfortable, even horrifying, as you start to want to be something else. (To the newly-diagnosed, I urge you, do not become your illness.) For years I resisted writing anything about my mental illness; now I worry constantly that when I do so, I pigeonhole and limit myself.

“People can feel freed by these stories,” Aviv writes, “but they can also get stuck in them… a role that at first seemed freeing, but it began to destroy them.” This is the most recurrent theme in Strangers to Ourselves: the double-edged sword of the stories we tell to make our disorders comprehensible. Aviv’s is the kind of mental illness narrative I trust and value the most: suspicious of narrative itself. It’s perhaps a kind I could even write myself. The bigger kind, the longer kind, the “and then this happened on this date” kind, is both beyond my abilities and against my best interest. As Aviv writes, “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”.