Through a handful of case studies, Aviv illustrates how our diagnostic and treatment frameworks for mental illness, which many in and outside of medicine accept as monolithic truths, necessarily cut us off from our indissoluble humanity. Every attempt at a solution has its own pitfalls, which Aviv counters with empathy and analytical acumen. The book, as she describes it, is about people whose experiences with mental illness fall outside of a “closed and complete system of truth.”
Aviv does not try to replace imperfect wisdom with her own. She is a dogged epistemological advocate for the opposite side of every argument. One of the most complex chapters in this regard traces the life of Ray Osheroff, a successful kidney specialist who owned several dialysis centers in the mid-1970s. After a divorce, when his wife moves to Europe with their sons and his business falters, he develops obsessive thoughts and depression. He checks into a psychiatric hospital called Chestnut Lodge, which promotes therapy and psychoanalytic insight as the best method of treating mental illness of all kinds.
The faculty is firmly against drugs. In a book quoted called Aviv The Psychiatry, Alfred Stanton and Morris Schwartz write that from its inception the Lodge sought to create a space that was ideologically opposed to “a society that feared and defended the ‘truly vitally human'”. Osheroff and his therapists at the lodge don’t seem to be making much headway. He cannot free himself from the cyclic thoughts about his supposed failure; He ponders the past and the outside forces that he believes pushed him from the pinnacle of his life. When the Lodge’s treatment fails to cure him, he moves to a hospital called Silver Hill, where doctors prescribe the antidepressant Elavil and Thorazine for restlessness and insomnia. He regains his “power of experience” – a term coined by Swiss psychiatrist Roland Kuhn, quoted by Aviv – and can finally mourn the separation from his sons for the first time.
In 1980, the medical director of the American Psychiatric Association announced that the publication of the DSM-III represented a victory for “science over ideology.” Two years later, Osheroff sued the lodge for malpractice, citing what he called their “therapy-only” approach; The lawsuit was seen as a turning point in the ideological split between psychoanalysis and neurobiology. The decades-dominant preference for insight-based talk therapy treatments was now on the wane.
Forty years later, the tension surrounding the use of medication for depression is still very much alive, but reconfigured for a new era. A CDC survey found that from 2015 to 2018, 13.2 percent of Americans took antidepressants, and globally, the number of people taking antidepressants has only increased during the pandemic years. Some journalists have suggested that more than 37 million Americans are taking SSRIs.
Despite this widespread acceptance, some dissenting perspectives have recently pierced their authority. In April of this year, PE Moskowitz published an article in The nation Challenging the orthodoxy of the rhetoric surrounding the use of SSRIs to treat anxiety and depression. Moskowitz discussed how, despite the widespread belief that stopping SSRIs does not cause withdrawal symptoms, studies have shown that over half of people who stop taking SSRIs report withdrawal symptoms, and in the studies that tested for severity , half of these people reported their withdrawal symptoms as severe. Thousands of people have gathered on sites like Surviving Antidepressants to share information on how to combat these symptoms. Moskowitz used the site to learn how to combat her withdrawal symptoms after stopping SSRIs, one of which was an adrenaline-fueled downfall that lasted for months and prompted many to contemplate suicide.
Like Moskowitz, Aviv notes that it disproves the popular belief that SSRI use is necessitated by “chemical imbalances” in the brain — that one’s anxiety or depression is simply due to a congenital or developed deficiency of serotonin or dopamine. A review published in the magazine this year Molecular Psychiatry showed that when looking at serotonin levels in the blood and brain fluids of tens of thousands of people, there was no difference between depressed and non-depressed people. Even when serotonin levels were artificially lowered, it did not cause depression in the non-depressed volunteers. Aviv argues that the chemical imbalance theory “perhaps survived so long because the reality—that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors—is harder to conceptualize, so nothing has taken its place. The theory feels so clean and intuitive — the lack of happy chemicals is saddening — that it’s almost heartbreaking to discard the perfectly crafted sense of it. But Aviv shows why it pays to abandon false reductionist theories for a more complex understanding of mental illness.
Outside of studies, polls, and statistics, Aviv wrestles with her own use of SSRIs, which she originally took for social anxiety, and has reported alarming and impractical withdrawal symptoms after trying to taper multiple times. “[F]When I first experienced depression, as described in textbooks,” she writes, “as an inability to move or act. Whatever illusion sustains the belief that one’s work has meaning and relevance has dissipated.” After going cold turkey on her medication from a planned pregnancy, she experienced depression and meaninglessness so intense that she thought about an abortion. Then she restarted her meds: “Within three weeks I felt reconnected to my reasons for having a baby.” While she’s “uncomfortable with the idea of a biochemical model explaining why [she] felt lonely or not,” she finally decides to keep using the drug, saying it makes her a better family member.
The book also introduces Bapu, a woman who finds solace in her sexist surroundings by immersing herself in Hindu spirituality; Naomi Gaines, a mother searching for answers after a devastating psychotic experience in a racist society; Laura Delano, a woman who refuses medication and analysis after a lifetime of diagnostic dead ends; and Hava, an anorexic woman struggling to shake off the condition, who Aviv met at the age of six during her own hospitalization for anorexia. Aviv carefully combs through the lives and personal documents of each of these women to chronicle their experiences with medical institutions. Anorexic, schizophrenic, psychotic—Aviv doesn’t necessarily deny these labels, even if her subjects would. But in an effort to understand these women’s experiences, she describes in detail the intricate interplay between these women’s environments and their inner worlds.
Aviv is particularly keen on the granular – by focusing on the unique makeup of each of these individuals’ perceptions, she is able to show how they shift form once they come into contact with perceptions crafted in the forge of social history. Is Bapu consumed by religious devotion? Or is she schizophrenic as diagnosed by western medicine? Through the interplay of these two perspectives, Aviv highlights a third, one that favors uncertainty and exploration, comparing the shackles of understanding but ultimately leaving them to their own incomplete picture.
Years after his malpractice lawsuit, Osheroff wrote—then rewrote and rewrote—a memoir. He had started therapy again and saw his depression differently. “This is not a disease,” he wrote in at least one version of his manuscript, “it is not a disease—it is a state of separation.” Aviv writes,
Two different stories about his illness, psychoanalytic and neurobiological, had failed him. Now he hoped that a new story, the memoirs he was writing, would save him. If he just got the story right or found the right words, he felt he could “finally reach the shores of the Land of Healing.”
In the end, “Osheroff felt that any story that solved his problems too completely was untrue and evaded the unknown.”
Mental health narrative frames can be liberating and they can be binding. We need them, but we also need to find a way not to get caught by them. Aviv’s writing does not see her strength in sweepingly swearing off mental health concepts or strategies, but instead showing that each frame is part of its own zeitgeist. That doesn’t necessarily make them wrong or even ineffective, but it’s important to understand how they’re part of a web of ideologies that morph and change over time. We should, of course, still take our solutions where we can find them, so long as we are not too attached to any notion of their perennial categorical truth.
Callie Hitchcock is a writer and a graduate of the NYU journalism master’s degree in cultural reporting and criticism. She has published in writing The believer, The new republic, Los Angeles Book Review, True life magazine and elsewhere.