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Rachel Aviv’s Journey to the Ends of Psychiatry

Janet Malcolm’s successor at The New Yorker has a different take on the impossible profession

Marco Roth
September 06, 2022
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Edward Carvalho-Monaghan
Edward Carvalho-Monaghan
Edward Carvalho-Monaghan
Edward Carvalho-Monaghan

When she was 6 years old, Rachel Aviv stopped eating; she thinks she might have got the idea from the Yom Kippur fast. She eventually found herself hospitalized in the Children’s Hospital of Michigan with one of the youngest ever diagnosed cases of anorexia nervosa.

On the “anorexia ward,” Rachel was befriended and mentored by two preteens, Hava and Carrie, who nurture her but also introduce her to the anorexic’s world of magical thinking, calorie counting and calorie burning (they applaud Rachel’s precocity for refusing to eat Cheerios but accepting a bagel, because hundreds of tiny o’s must be more filling than one big O). After six weeks of a reward-punishment regime that allowed young Rachel contact with her parents and sister only if she ate specific quantities of food per day, she gained enough weight to be discharged.

At this point, her recently divorced parents made one of the best decisions of their lives: They refused to listen to the advice of psychiatric professionals, who recommended Rachel should be taken out of school and placed in a mental hospital. “I feared once you’d gone into that system of psychiatric institutions it may have been very difficult to pull you out,” her mother later tells her adult daughter. Instead, her parents treated Rachel’s anorexia as a phase rather than a condition, something that young Rachel had outgrown and moved beyond. Aviv herself came to regard it this way for the rest of her childhood and adolescence, a mysterious zone in her consciousness akin to the “porousness” she sometimes felt about the boundaries of her being.

Thirty-odd years later, Aviv is now a star staff reporter for The New Yorker and the heir to the magazine’s unofficial position of “psychoanalysis and psychiatry correspondent,” formerly held by the late, great Janet Malcolm. The other people profiled in Aviv’s début collection, Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, are all much less fortunate than she is: Ray Osheroff, a successful nephrologist and loving father succumbs in middle age to something then diagnosed as manic depression; he agrees to be institutionalized at the Chestnut Lodge mental institution—known for its rigorous, almost cultlike, devotion to Freudian analysis. He ends up suing them for malpractice for refusing to give him antidepressants and his case became a cause celèbre in the 1980s assault on institutional psychoanalysis. Ray never really recovers a stable identity—or any kind of meaningful existence—and remains estranged from his children until the end of his life. Bapu, a Tamil woman from Chennai, shortly after her arranged marriage, transforms into a rare female Hindu mystic—publishing two books of devotional poems to Krishna in archaic medieval meters. Treated as a schizophrenic by her husband and family, she drifts in and out of horrific mental institutions and various antipsychotic prescriptions, punctuated by bouts of flight and homelessness, leaving her children with a tangled legacy of genius, madness, guilt, and unfulfilled love.

Naomi—an African American woman born to a single mother in one of Chicago’s worst housing projects—experiences a psychotic episode familiar to readers of Toni Morrison’s Beloved: One Fourth of July, in Minneapolis, she believes she and her children are going to be lynched by a mostly white crowd, so she jumps from a bridge with her two toddler twin boys. She and one of the twins are rescued. Naomi is convicted of the second-degree murder of her other son; an insanity plea is rejected; nevertheless she is forcibly medicated with antipsychotics—until they become too expensive—while serving 15 years in a woman’s prison. At the other end of the American social spectrum is Laura Delano—yes, she’s related to Franklin Delano Roosevelt—a top one-percenter within the 1%—classic overachiever, Harvard-bound, squash player who will also overachieve as a psychiatric patient. In the book’s final chapter, Aviv returns to her childhood ward mate, Hava, to trace out what Aviv calls her “illness career.”

Aviv has brought her unfortunate early encounters with the therapeutic establishment—in its psychiatric and social-institutional forms—into her reporting. Each of the profiles collected in this volume raises a set of questions about the inadequacies of various mental health regimes to benefit those they’re trying to help. In loose chronological fashion, the cases span a time from the waning worldwide influence of Freudian psychoanalytic psychotherapy to the present moment’s brain-based fads. Aviv approaches her critiques obliquely and suggestively, through in-depth reports on individuals based on their letters, diaries, interviews with family members, friends, medical records, doctors, and, when possible, the subjects themselves.

Strangers to Ourselves adds anecdotal and emotional weight to a growing body of evidence that the progressive narrative of mental health is largely fictitious. Psychiatry is not much closer to “curing” or even significantly mitigating the sufferings of the majority of those diagnosed with a mental illness than it was 100 or 200 years ago. For those looking for harder evidence for this thesis than Aviv’s anecdotal treatments, there’s the empirical sociologist Andrew Scull’s recently published Desperate Remedies—a history of American psychiatry with crucial chapters on the licensed conflicts of interest underwriting “double blind” drug trials, the official diagnostic criteria outlined in the famous DSM, and the insurer-driven model of mental health care. At best—decades after the debunking of Freud, the heroic years of Listening to Prozac and the supposed triumph of the brain over the mind—the psychiatric establishment has created a dependent class of medicalized consumers who either treat the side-effects of one brain-altering drug with others, or else use an array of medically approved wellness therapies to retrain their behaviors for as long as their insurance holds out.

Aviv then takes things a step further—and perhaps too far: She suggests that our faults are neither in our stars (our biology) nor ourselves (our minds in response to our environment) but in the stories medical professionals tell about those faults and how willing we are to accept them. A diagnosis is a kind of seduction or invitation. Aviv quotes the philosopher of science Ian Hacking’s aphorism that, “We make ourselves in our own scientific image of the kinds of people it is possible to be.” Instead of this “scientific image,” Aviv focuses her book on “missing stories, the facets of identity that our theories of the mind fail to capture ... I find myself searching for the gap between people’s actual experiences and the stories that organize their suffering.”

The classic case study, whether psychoanalytic or neurological (think Freud or Oliver Sacks), was narrated by the doctor and focused almost exclusively on the relationship between doctor and patient. The journalistic variant—pioneered by Janet Malcolm, in, for instance, her account of dynamic family therapy in the late 1970s—made both doctors and patients the subjects of the journalist’s unflinching, skeptical gaze, proceeding somewhat in the manner of a Greek tragedy with a chorus made up of other experts, students, and family members.

Aviv’s variant is notable in two ways: Doctors are demoted to secondary or tertiary characters, their interventions usually malevolent or obtuse; and, secondly, when dealing with living subjects, she focuses on “horizontal” or nonhierarchical relationships—Naomi’s with her fellow prisoners, the prison librarian, and the older white man who rescued her from the waters of the Mississippi; Laura’s with the online community of the overmedicated, her sister, and her boyfriend, and Aviv with her own friend group, dubbed by one of them “ambitious ladies,” all of whom are on forms of antidepressant drugs. What Aviv calls “identity” or sometimes the self (never the “ego”), is presented as a community project, a group dynamic more than an individual quest. Experience is shareable, and thereby becomes productively meaningful, in a way that the narrative frames suggested by authorities and institutions are not.

Central to this project—which is presented as a skeptical challenge to the medical establishment rather than a developed argument—is Aviv’s rejection of “insight.” A term with positive connotations in ordinary language, “insight,” as a psychiatric term of art, refers to the degree that a committed mental patient understands him or herself as a crazy person. “In the starkest terms,” Aviv writes, “insight measures the degree to which the patient agrees with her doctor’s interpretation.”

In other words, as Aviv sees it, the acceptance of diagnosis is a stage in the deepening of one’s illness. Of her own case, Aviv writes, “I was recruited for Anorexia, but the illness never became ‘a career.’ It didn’t provide the language with which I came to understand myself.”

The idea that self-knowledge for the mentally ill is a kind of “self-own” has a certain intuitive appeal. After all, our world is increasingly run by high-functioning sickos of one stripe or another: sociopaths, narcissists, borderline personality types, spectrumey savants for whom acknowledgment of feelings—whether one’s own or others’—presents as an evolutionary disadvantage. It doesn’t matter what diagnosis we or the APA give them; they all keep on truckin’ like the do-dah man, thriving off the frustrated desires and donated dollars of us poor neurotic saps and suckers. If the United States were to choose a motto for the pediment of its Delphic oracle, it would read “a sucker is born every minute” instead of “know thyself.”

A responsible journalist for a magazine whose unstinting appreciation of its own importance is reflected on hundreds of thousands of tote bags proudly paraded through America’s most highly educated ZIP codes, Aviv would never go so far as to endorse a revival of R.D. Laing’s and Thomas Szasz’s radical anti-psychiatry movement of the 1970s. Nor is she a cheerleader for more recent efforts spearheaded by the journalist Robert Whitaker to combat America’s pill-industrial complex. In the chapter devoted to Laura Delano, the model student who becomes the model patient, before eventually rebelling, Aviv slaloms around the problems of contemporary anti-psychiatry. She acknowledges that just as psychoanalysis in its heyday became an interminable, chronic, even aspirational condition for its analysands, so too now with psychopharmacology. But, neither does she endorse the view best expressed in a witty piece of French graffiti, “Il n’est pas bon signe d’être bien integré dans une societé complètement malade!” Those who do feel this way, she writes, “diminish the reality of mental disability.”

At the same time, Aviv appears to hedge her bets when it comes to the question of whether even florid cases of mental illness are “real.” While Aviv leaves no doubt that the Indian mystic—Bapu—is schizophrenic rather than divinely touched, in the case of Naomi, the Black woman who accidentally murdered one of her children, Aviv cites her refusal to accept that she was mentally ill, and approvingly quotes Naomi speaking about the insight revealed to her by one of the voices she heard, “I felt I was being shown things that were being hidden from me all my life about the reality of me as a Black woman in America raising children.” While it’s highly probable that in a society without America’s history of slavery and oppression, the content of Naomi’s persecution delusion would have taken on a different and, one might hope, less fatal form, it’s a stretch to say that Naomi’s insight into “the reality of me”—purchased at the high price of the death of her child—was a consequence of purely social and historical factors.

For Aviv, society is therefore to blame, except when it isn’t: In the case of the more privileged, “chronically overmedicated” white women, Aviv summons her skepticism and wonders whether Delano’s identity switch from obedient pill-popper to proselytizing blogger and influencer for those looking to wean themselves off their dependence on medication might not be a form of self-deception rather than self-realization, albeit a more functional one than her previous identity as a patient.

In an attempt to rebalance the equation, Aviv recounts her own use of the antidepressant Lexapro, “a six-month experiment [that] has now spanned more than a decade.” Rather than interpreting the results of this “experiment” as a sign of an alarming dependency, Aviv credits the drug with helping her become a less anxious, happier, more highly functioning person. “Lexapro tracks closely with the development of my career. It also corresponds with the period in which my boyfriend and I decided to get married. Perhaps I would have reached these milestones anyway, but I cannot cleanly separate them from the medication.” Later she acknowledges that “merely the idea of swallowing such a thing has healing power.”

When it comes to her own self, at least, Aviv has reached a place where she “know[s] to know no more,” as the angel Raphael warns Adam, before the fall, in Milton’s Paradise Lost. A good treatment is whatever produces a good outcome, goodness here being measured in terms of the conventional outcomes of social reproduction: successful career, happiness in love, and motherhood.

In this and other ways, Aviv reveals herself to be a disciple of the American pragmatist philosopher and psychologist William James. (Aviv cites James only once in her book, but the implicit influence is much stronger than the explicit one.) By his own account, James was cured of his own suicidal depression by the realization that he could choose “to believe in my own individual reality and creative power,” even if others attempted to persuade him that his thoughts were only illusions or delusions. This in turn led him to his formulation that “the truth is only what proves itself to be good in the way of belief.” Similarly, if Aviv believes that antidepressants are necessary to her happiness and success, then antidepressants work for her. If, on the other hand, someone comes to believe their psychiatrist is using drugs to cripple and enslave them, then drugs are not the solution.

At its most cogent, Strangers to Ourselves appears to be making a case for the equal agency of those with mental health issues to determine their own treatments. Mental health thus becomes neither a matter for professional scientific institutions nor the state. Rather, it is the private business of each one of us to arrive—through trial and error—at whatever we might say works, within the context of our own beliefs.

Yet this Jamesian libertarianism, however delightful in theory, remains subject in practice to the strong gravitational pull of other forces, which should not be difficult at this juncture in history to identify: The availability of medications is guided by the desire of drug companies for profits and by insurance bureaucrats who casually appoint themselves supreme arbiters of risk and reward for the entire American population; religious institutions and cults require converts; the state prefers an obedient, law-abiding populace; other citizens are often afraid of having their own private realities impinged on by people who can conduct loud conversations with invisible beings on the streets without benefit of an iPhone. Private good is inevitably a public question.

At the same time, there does seem to be something valuable in the lay concept of “insight” that Aviv seems eager to kick to the curb. It used to be that we were able to meet strange desires and apparitions within ourselves and come to more intimate forms of understanding with them, in collaboration with that now much-maligned and misunderstood figure of the psychoanalyst (and now the lay psychotherapist who is paid for by medical insurance). Aviv’s fascinating albeit largely unconscious (by which I mean unintended) book-length argument against “insight” throws out the possibility of such psychoanalytic or psychotherapeutic recognitions and transformation, and with it the depth psychology model of selfhood, along with bathwater of its various abuses and failed applications through the years.

In one of her more optimistic statements concerning what she elsewhere called the “impossible profession,” Aviv’s predecessor at The New Yorker, Janet Malcom writes, “Psychoanalysis seeks to acquaint us with and free us from the tyranny of the artist within us, who insists on an impossible order, who schemes and arranges to make things come out right, who commits us to a foolish, sometimes even dangerous adherence to l’art pour l’art.” For Malcolm, an orthodox Freudian who was often more rigorous than Freud himself, the analytic project was, from its beginnings, determined to deliver us from what Aviv calls “the stories that make us”—or at least enable us to see them as stories rather than destinies. The story Aviv tells about herself, her narrow avoidance of an “illness career”—unlike her earlier ward mate, Hava, with whom she identified—comes to sound very much like one of these tyrannical artist stories, with the key contemporary term “career” replacing the metaphor of the demanding, internal artist who commits us to perfection and meaning. Another such story is Aviv’s discovery of a magic drug that enables her to obtain all the goods a “normal” person might hope for, even as the drugs to which tens of millions of Americans like Rachel Aviv credited their achievement of mental balance and various forms of normalcy now seem likely to be a sophisticated type of placebo.

Culturally speaking, we are too old to believe the fairy tale that psychotherapy offers a cure for everything that ails our minds and brains. Yet our modern pill fetishes seem if anything less mentally enriching, and often more toxic. The strength of Janet Malcolm’s work was her ability to understand the pitfalls of Freudian psychiatry and the foibles of its adepts through a Freudian lens. By comparison, Aviv’s pragmatism seeks to dissolve the animating tension of her great predecessor’s approach by ignoring the existence of a reality beyond the shadows on the walls of one’s private cave. There is at once a cynicism and an innocence in asserting that the existential problems that bedevil humans can best be ameliorated by denying the possibility of insight into a reality that can’t really be said to exist, anyway. If that sacrifice, or series of sacrifices, born of denial, makes Rachel Aviv and her circle of friends happy in their lives as high-achieving career women and mothers, then I’m happy for them. It’s the rest of us I worry about.

Marco Roth is Tablet’s Critic at Large.