 Hi, welcome and thank you for joining the New America Fellows Program and Future Tents for this discussion of Rachel Aviv's beautiful, beautiful book, Strangers to Ourselves, Unsettled Minds, and the Stories That Make Us. I'm Larissa McFarker, a 2018 Emerson Collective Fellow. Before we start, a few housekeeping notes. First of all, if you have questions during the event, please submit them through the Q&A function and we will get to them in the second half of the event. Roughly like the last 15 minutes will be audience Q&A. And most importantly, copies of Strangers to Ourselves are available for purchase through our Bookselling Partners Solid State Books. And you can find a link to buy the book on this page. Just click by the book and I really, really urge you to do so. It's one of the best books I've ever read. So Rachel Aviv is a staff writer at The New Yorker where she writes about medicine, education, criminal justice, and other subjects. In 2022, she won a National Magazine Award for Profile Writing. A 2019 National Fellow at New America, she received a Wedding Creative Nonfiction Grant to support her work on Strangers to Ourselves. So welcome, Rachel. Thank you for. So much for doing this. Thank you for being part of this. So I want to begin at the beginning of your book. You open it with a story about yourself as a child and you're coming to realize that your life could have turned out very differently. And I wondered if you could tell us a bit about that experience and how it led to you writing this book? Well, it had been this kind of like episode in my life that I didn't quite know how to categorize or what to do with it. It just felt like this freakish thing that had happened to me. And just to summarize quickly, when I was six, my parents were getting divorced and I stopped eating for a couple of days and my mom took me to the pediatrician. And it just sort of escalated very quickly where the pediatrician said, oh, this is anorexia because she's not eating. And it was the late 80s when anorexia was just like in the cultural consciousness as this new threatening thing. And then I was put in a hospital. And once I was in the hospital, like the behaviors sort of got worse. And I think one of the reasons why is because I was surrounded by these amazing older girls. And I sort of saw them as mentor figures and wanted to be liked by them. And I had this kind of like strange disperse behavior. And they kind of helped me like channel it into a more recognizable form of illness. Whereas before, maybe my behavior was like an expression of anger, helplessness or something, but it like, it wasn't organized. And when I was in the hospital, it became organized. And then I think I really wasn't thinking that much about this moment in my life in a way that I found interesting until I was writing a story for The New Yorker. And I think it was 2017. And I wrote about these children in Sweden who suddenly lost the ability to talk and move and they stopped eating. And this all happened when their families would be denied asylum to Sweden. They were refugees there. And I think I just, there was something that resonated with me about like a child who displays some sort of behavior protest. But in a, but their social and cultural context kind of like changes the way that behavior is interpreted. And because the behavior, the interpretation changes, the behavior can also change. So I became interested in that kind of like interactive dynamic between a person's identity and the diagnosis or the way that their behavior has been categorized. Is that, yeah. Well, I mean, reading about you as a six-year-old and these older girls who, you know, one thing that became really clear to me, and you do say this in the book, is that your ignorance was protective. The fact that you were six and had never heard of anorexia, could barely pronounce it, didn't understand at all the cultural meaning of it, or what you were supposed to be doing, was very protective of you. Whereas the older girls, and I would say also Laura, another person you write about in another chapter, their psychiatric sophistication sort of made them worse. And so I was wondering if, you know, there's so, now, even more than the 80s, the stories about mental illness and sophisticated understandings of mental illness are so omnipresent. And I was wondering if you think that's doing us harm. I mean, I think that is a really interesting question. Like, I feel like people have asked me a lot about tic-tac, which I don't know that much about, but like this idea of like having some behavior, and then like finding a community. And I guess what I feel is that like, it's not predictable. And I think there has been an assumption that it's always good. It is always good to talk about mental illness, to identify it, to label it. It will always reduce stigma, and that's just sort of something we take for granted. And I guess I think that in many cases, it probably still is very good to talk about these things. But like we don't actually, I think we think about talking about it as like a neutral thing, like we're just describing what is. And I think I was interested in the fact that like talking about mental illness isn't always neutral, like it actually changes the behavior itself. And sometimes it reinforces or exacerbates that behavior. And I think we kind of know that with suicide, like suicide is one area in mental health where I think people don't take that kind of like approach of the more we talk about it, the better. Like we're sensitive that suicide can be contagious, that suicide can be something that when someone thinks about it kind of takes root in them. But I wonder if we've like carved out suicide as the exception without thinking about the ways that there are parallels with other sorts of illnesses. Well, I mean, along the same lines, one thing you you talk about quite a bit is the idea of insight and the role that insight plays in the way that doctors evaluate their patients. And at one point you said, it became apparent that gaining insight into interpersonal conflicts, though intellectually rewarding, did not provide a cure. And this was startling to me. I it sounds as though perhaps because of psychopharmacology that insight has gone completely out of fashion. And I was wondering if you could just I mean, of course, there's there are now have always been different schools of thought on this within psychiatry. Could you say something about what you discovered about insight and how it how it's viewed now, as opposed to in in let's say 50 years ago? I think the insight is still seen as a valuable thing, but it's like what it means to be insightful has changed a lot. And it is like there. It's sad to think about I mean, the idea that like if you just understand what caused your problems, you'll get better is just like so wonderful. Like I can see why that would be like this amazing organizing principle for a field of psychiatry. And I still think like, I don't think anyone's like thrown out that idea. But I think people saw, I think it was like this moment of disenchantment to see that someone, you know, was in therapy for nine years and not improving. And they take a medication and they suddenly improve. And like, you can sort of say, Oh, well, the therapy like prepared them to enter that state. But I think ultimately, like there has to be a recognition that, you know, that the insights were pretty limited in terms of how it was changing someone's life. But I think like now insight is used in this more descriptive way, which is like if it's if someone comes into a hospital, and they're displaying all this strange behavior. And the psychiatrist says like you have bipolar disorder. And the person says, No, I don't like, I'm actually just like an incredibly talented poet who can like speak the truth. And I'm speaking the truth. Like that person might be seen as not insightful. And I mean, that that wasn't a great example. But I think like where it becomes more difficult is when someone is, you know, in the chapter about Naomi, who was this woman who came in and felt like she had just discovered like how racism had shaped her life and her children's life. And she really wanted to talk about that. And so when she would talk about that with her psychiatrist, they felt like she was sort of putting the emphasis on the wrong issue, the right issue was that she had bipolar disorder. And that was why her life was, you know, going off the rails. And when they would tell her that for her, it was alienating and sort of proof that she shouldn't trust the doctors because they weren't actually like hearing the problem that she said was causing her suffering. But I think like insight is interesting to me, in part because it's one of those rare concepts that like brings together the gap between how a person is describing their distress versus like the theories that are supposed to explain their distress or the explanations. And it's like insight sort of measures that match like does the person's own explanation match the sort of Oxford explanation. I mean, that I'm torn between asking you to talk more about Naomi and I mean, just to that that that that discrepancy comes up in every one of your stories. But I wonder if you could just talk about Ray first, because I mean, you know, you put him at the beginning of your book because his case sort of lays out the battle within psychiatry that is still going on to some extent, though, in some ways, one side is one, could you just tell us about him and why his case was so important and how it sort of is resonating even now? Well, I had seen references to his case, like, for the last maybe 15 years, and it was always this thing of like Ray Osharoff's case proved kind of proved that that it was medical malpractice if a doctor denied a patient medication. And so he'd been treated at this really famous psychoanalytic institute, Chestnut Lodge. And he was getting worse and worse. And he was a good like when this was taking place. All right, good point. This was in 1979. So it was like the heyday of like believing it that like if you just talk to someone and like here, you really understand them. They always make sense, like this belief that like no matter how sick someone is, you can reach them if you just listen, and you'll sort of reach a kind of mutual understanding. And so he went to this place, and he kept talking and talking about all the things that had made him depressed, because he was a doctor and sort of his marriage wasn't working. And he felt like estranged from his children. And Chestnut Lodge felt like he needed to sort of work on his personality and work on his relationship with people. And when he asked for medication, they felt like it was a way of sort of skirting like the real fundamental issues that he wasn't addressing. And finally, his mother pulled him out of the hospital and sent him to a different hospital where he got medication. And like, it was just this incredible metamorphosis where suddenly he was like a funny sensitive man who who could function in the world and who sort of could appreciate life. And so then he was so angry that he'd been like denied that treatment that he sued Chestnut Lodge. And I thought that a story was like, that was the most frustrating chapter to write, in part because, you know, I thought it was like important in terms of the ideas like these, you know, these two dominant models in psychiatry colliding and the sense that one had to win. And then when I read Ray had kept this, these diaries and he'd written a memoir that was never published. And when I read the drafts of his memoir, I just was really aware of how, even though he thought that his story was supposed to be like an illustration of the triumph of biological psychiatry, it just wasn't. But he what was so frustrating to me is that I also wondered if it was like his personality that had made him that had made the psychoanalysts not know what to do with him that like they just didn't like him. And so they had these like beautiful theories. But when it came down to it, like they didn't want to apply those beautiful theories to someone who was so annoying. Yeah, he is extremely annoying. I was just saying, I'm thankful that you read his memoirs that we don't have to. But there, I mean, along those same lines, you quote another psychiatrist, Clermann, this great phrase that I love pharmacological Calvinism. I wonder if you could explain what that was and why it exerted a pull on people. And then I was also wondering to what extent it has a pull on you. Yeah, no, I think it's like such a good word because I feel it even today. But I think at the time he was saying, like, we need to get rid of this suspicion that if you're using medication, it's somehow is a sign that you'll you haven't done like the good hard thing you've taken the cheap out and you'll have to pay for it somehow. But I think, yeah, I think that's like a persistent thought. And I don't, I think I'm torn between feeling there has to be something valuable about like figuring things out on your own and like fixing one's problems through like thinking and analysis and communication as opposed to like there is something about taking a pill that feels so easy that I think that yeah, he articulated something that like really it like speaks. Yeah, it speaks to me, you know, even now. I mean, you talk about about your experience and that of many of your friends taking lexapro and that everyone I think everyone feels that feels dissatisfied with being on it even if it's having fully benign effects. And I was wondering if you could think about that a bit like what like why does everyone seem to feel the need to dial off a medication if it's making their lives better? I mean, so I wrote about my friend Helen who at the time that I went on lexapro, she went on it too. We were both like having amazing conversations like just enjoying life so much. And then she was like, this is fake. This is inauthentic. I don't think she's a writer. She didn't think she would write as well without it. And so she stopped the lexapro. And then she like read the section of my book about us and was like, what is wrong with me? Like why did I deprive myself of this? But I don't know. I also like I don't I think that we don't actually know like how it's changed our sex lives. Like I think that that is something that's like this weird missing piece in conversations about medications that I just think it's interesting that it is so often, you know, women, particularly white women who take these kinds of authorize and that they're sort of seen as risk free, but they actually do have like a profound effect on people's sex lives. And it's interesting to me that somehow that's not seen as like a profound side effect. It's kind of like whatever, there's no risk. But but like maybe there's a failure to sort of think about people's relationship with sexuality as much as sort of seriously as might be good. I don't know. Because I don't think like I feel fairly confident that I'll just like keep staying on like Supro, but I but I almost don't think about the sexual aspect of it. And I think that is real. That's that is really different. Interesting. Because I mean, it's almost as though impenetra for psychoanalysis is, you know, by stereotype obsession with sex, that sex was the root of everything that now this field has swung all the way in the other direction. And it's like, well, who cares about sex as long as your career is going well. Right. As long as you can have a family in a career. And like that, those are the advertisements for SSRIs. It's like these women who have their kids and their wedding ring and like they're wearing a work suit. And it's true, like it does, it does make I feel that it allows people to like manage those conflicting sort of obligations or desires better. But it kind of leaked and I don't think it speaks just to psychiatry. I think it also speaks to like I remember Francis saying like he could never understand that when the new generation of SSRIs, Alan Francis was like help write the one of the earlier versions of the DSM and he said that when the new antidepressants, the SSRIs replaced the previous generation, everyone was like, these are amazing. There's no side effects. And he felt like, what does that say about our culture that like this really extreme side effect is just like no one really cares to talk about it. Yeah, I mean, seriously, that could be a whole other book. Well, another really interesting thing that I had never heard before I read your book was, I mean, the thing that I'd always heard was that when biochemical explanations for mental illness became preeminent over psychological ones, that one of the things that people said about that was that it would reduce stigma that it wasn't, you know, both stigma of you, like it's not you being lazy or feckless or something, and also towards your family, like it's not the refrigerator mother anymore, who's causing your illness, it's it's just the chemicals in your brain. That part I'd heard, but what I'd never heard before is you said that that the effect of this explanation has been different for different kinds of patients. So whereas with rich white patients like your character Laura, it is experienced as a reduction in stigma with you quote, an anthropologist who's worked with poor black and brown patients. And she finds I think it's a woman that like like your character Naomi, that this is not at all welcomed as an explanation of what they're going through and they experience it very differently. Could you could you say a bit about that? I think what you know, the way that she put it was first that she noticed that when she's an anthropologist, but also psychiatrist, and she said that when she talks to patients and they're able to sort of say like, I'm so unhappy, I'm so sort of this mentally disorganized right now because of the way I grew up and because of the like lack of support in my community and like, that is very empowering and healing for them, maybe in the same way that someone used to say like, I'm so upset because my mother was like toxic and dysfunctional, but like, she's basically saying that to deprive to sort of tell someone whose life has been shaped by all these really like cruel, oppressive forces, that it's just in your biology that you're not responding to all the things that have happened to you, that is diminishing. And that yes, for like someone like Laura, who really didn't have any like discernible conflict in her life that feels very visible, then she feels it's not her own fault, but like for someone like Naomi, who grew up in a public housing complex and poverty, like with lots of violence all around her, to be told that, you know, it's just in her body is sort of really denying her reality, which is that like all of these stressors sort of put her on the edge. I want to ask you more about Naomi in a second, but I just want to remind everyone listening to this that you should be thinking if you want to about questions to ask to ask Rachel, because we're going to go to questions in about like 20 minutes or so. I'll say one more thing to simplify it, like I feel like with Laura, the woman she went to Harvard, she grew up in Greenwich, Connecticut, like because there was nothing like clearly wrong in her life, it was easier for her doctors to not see like the various things that were cause of great discomfort and to sort of say it was biology, where she too might have like understood more about herself if she could talk about all the ways in which like she did feel uncomfortable at Harvard, even though it like, you know, when her doctors, because of their own cultural background, probably felt like, you know, why would anyone feel uncomfortable there? It's wonderful for her, but like she felt like it had to be within her, it had to be her biology because her life was like visibly perfect. Right, right, right. Well, so tell, can you talk a bit about Naomi and I mean one of the both about the terrible things that happened to her in her life and also about the way, the bind that she found herself in when on the one hand her explanation, her psychiatrists dismissed her explanations for her distress and then in court, those explanations proved overly powerful. Yeah, could you just say a bit about her story? So she was a single mother of four kids by the time she was 24 and she kind of started reading about the history of Black people in America and like having started having this awakening that like her whole life had been shaped by discrimination and racism and that her kids were going to grow up in this sort of trap that she had grown up in and she became more and more psychotic and went to a bridge and jumped off with her children thinking that like some sort of evil government force was going to get her and one of the child children died and one was saved and when she was in the hospital she basically talked about how she had reached this point where she kind of understood what life would look like for her children and that's why she did what she did and when she was evaluated to see if she was competent stand trial they said she was that she couldn't plead insanity because like her sociological insights were true like what she was seeing about her environment they understood to be true so they were like she can't be insane and I think like the irony is that before she committed her crime she was sort of saying those same things but her doctors weren't really engaging with those things at that time at that time they were like why aren't you understanding your bipolar like you need to recognize your bipolar and then there was this shift where like suddenly the truth of what she was saying felt so prominent that she couldn't possibly be insane yeah an amazing bind so with Naomi's case her account of her unhappiness is clearly reality-based another one of the stories an incredibly moving story in your book it's really harder to figure out what is real what isn't real or do those words even make any sense so I mean you know what I'm gonna say like so there's always been a kind of entangling between religious experience and what's called mental illness by other people you know there's there's even with anorexia in both in medieval times and in the 19th century there's been widespread instances of women fasting which is interpreted religiously and then in other contexts it's interpreted psychiatrically and you know it's it's very common manifestation of what's called by psychiatrist schizophrenia that that people will talk with god or even imagine they are god or related to god I wonder if you could talk a bit about bapu and how you understand her life how how you entangle a disentangle religious experience from psychiatric category and does it even make sense to try to do that yeah I think I like landed on this in the space of like not want not trying to disentangle them because it's like every time I would talk to one of her family members their approach well I'll I'll just summarize should I summarize yeah tell tell us about who she is so she um was living in shinai in the 60s and she became a young mother and after she had these two kids she was she was living in this like large um brahman family and there were a lot of pressures on her and she started retreating to her prayer room and becoming increasingly spiritual to the point like at first people really thought she had this gift and they she wrote this incredible poetry and it was like celebrated as a sign of sort of communicating with god but then like she went too far kind of for her family and started running away to healing temples and then they would like drag her back with police vans and she was diagnosed with schizophrenia and it sort of this pattern of running away from home to these healing temples where she was embraced as a kind of mystic persisted for like 10 or 15 years um and when I talked to I talked to her two daughters uh two children a lot one was the daughter one was the son and they had such different views of what she had been through and it sort of structured their lives around like their interpretation of their mother's life like um the son had become very religious and felt like he was almost like continuing her legacy as a person who had access to the divine and his daughter and her daughter had become like a mental health activist who is arguing for a more complicated way of understanding mental illness but but fundamentally like couldn't have memories of her mother like starving and and being dirty and really unhealthy and to her like that was such an expression of disability that she couldn't say like my mother was you know with god in those moments like that like her mother was actually suffering so I think she came to the space of feeling like it didn't really matter what what she was calling it but like her mother was suffering and therefore that's why she needed like medical help and what how do you think about it like which when you're talking to those two children who do you find yourself why would you agree with both of them or how do you think about it well I'm like skeptical of my own biases so I guess I tried to like like my bias would be like I don't have a spiritual relation I don't have like a spirituality um as a profoundly unspiritual person uh I guess I'm more like I don't even know what to do with the spiritual understanding except for like feel there's something to be honored about it and like sort of feel in awe of the way in which it can structure people's lives um so I guess I I was thinking about this I was like reading for some reason I was reading your amazon page of your book I know and it said like you're very non-judgmental and I was thinking because a lot of people have asked me like why I'm non-judgmental but I almost feel like in this story I I truly didn't have like a secret feeling about it like I really every time I would talk to someone my understanding of the situation would change except for the fact that I have like a built-in difficulty understanding like getting my head inside the mind of spirituality like I can only see it from afar um I think your your story makes it so clear that to ask the question is this spirituality or is this mental illness it's the wrong question like there is no answer there's no you know nothing depends on on answering it correctly because it's it's it's the wrong question I I think I mean that's uh and I think that like I guess why the reason why I think it's the wrong question is because it assumes that there's like one explanation or one model that will be like the healing model and I think it was clear to me a bapu story and other people's stories too that like they were able to hold different explanations at the same time like numerous explanations at the same time like um sort of shifting between explanations or even you know simultaneously having multiple explanations and I don't know I think like it's a weird impulse that we have that you have to choose one um that like and at the end of her life bapu took medications while like furiously writing to um deities and so like she was able to sort of straddle both worlds without getting so like pulled out of them that you know I think the thing that her daughter said was that when she was at her like most I guess sick would be the word like she wasn't the thing she wanted in life like to have a family she was no longer having a family she like had abandoned them so I I guess like in this very practical way that feels like a sign of sickness to sort of you know to deny yourself of like the thing that for you is like constitutive of a good life huh because that's interesting because I I didn't get that from your story that she wanted a family I mean I think what I got was that once she had children she loved them and and missed them when she was away from them but that the desire to have a family was never it didn't seem to be one of her goals right I think that's the wrong I used the wrong word not family but that like being away from her children was a source of grief like a life no the family was like the baggage that she didn't want but it was right um so so in that chapter you quote this um Indian psychiatrist of the 90 I think 1960s NC Surya um saying that he didn't accept the western notion of mental health as a kind of statistical norm because Indian healing cultures were meant to raise the self to a higher ideal like the goal is not to be normal the goal is to be better than normal um detached spontaneous free of ego rather than simply to restore the person to a baseline of normality and Surya ended up quitting psychiatry you said and entering an ashram and I was struck by that because in the context of bapu story his notion of mental health as a kind of aspirational idea is more capacious than the western notion but it's also much more demanding and kind of punitive is the wrong word but demanding and I was wondering how you thought about that as what you in having written that chapter how you think about the western notion of mental health as being more or less normal like like other people like something you said that I think is really interesting as yeah it is more punitive it is more demanding it is more aspirational that model but I also think like so much of mental illness is that sense of um purposelessness aimlessness or lostness um like not knowing where you position yourself and so there's something very appealing about even if it's punitive and maybe this is like this sort of anorexic kind of approach to mental health but there is you know I can see why like just aspiring to be healthy is like so um there's something deflating about it you know like and then what and then what do you do with your life like how do you fill your days um anything treatment is focused on like getting rid of symptoms but like then what and I and I think that there are these dynamics where people get rid of their symptoms and their life feels sort of like they're living in a you know group home and they're taking their medications and they're like working a menial job but like actually they look back on their moments of psychosis and they felt like they were touching something like reaching for something and no matter how like detached from reality that was maybe there is an nostalgia for that yeah I mean I guess that's the sort of function of a religious tradition is to unify um the quest for health and also self-perfection whereas in sort of ordinary western psychiatry there's sort of two stages like first you just get to be healthy and your health is merely a tool for you to accomplish other things that have no relationship like like the perfection of your mind is not really it would probably uh you know someone went into a psychiatrist's office and said I I want to perfect myself um that would probably be taken as a symptom in itself you actually love a system that like told me how to do that like that sounds so the way you're describing it because then I do think you kind of like you have sort of like the SSRI ads like you can achieve these like two categories your work or your family but like there's still so much missing in between well so again on this theme of um of of how culture affects um a sense of mental health mental illness um you write culture shapes the scripts that expressions of distress will follow and um you know I love the work of Ian Hacking who you quote and I would I would love you to uh say something about him but but so what I'm what I was going to ask you about that quote that I just read is do you mean that mental distress is a kind of universal substrate that kind of takes a form depending on the repertoire of understandings available to the person in their time and place um or is it more murky than that I mean another way of asking the same question is is um I don't know if it still aspires to do this but at the time of the the sort of DSM three psychiatry was aspiring though not achieving yet to carve nature at its joints you know the ultimate goal which it was not uh claiming to have achieved was to find the sort of real dividing lines between mental illnesses in the way that um you know medical doctors or other kinds of doctors could determine that something was either due to the heart or due to the lungs but not get confused between the two um so I guess I was I was the question is like whether you think that um that the discovering such carving nature at its joints is is in theory possible with mental illness or do you think that cultural difference goes all the way down that it doesn't again make sense to ask um you know is this a thing that appears in another culture really schizophrenia or really depression or you know I mean I think it's striking that like that that task of like carving nature at its joints for mental illness it's now been 50 years that scientists have been trying to do that and so like I can't speak to whether like that's an attainable goal but like the fact that 50 years have been so many resources have been devoted towards that goal and I imagine like those resources are taken away from thinking also about um you know I like the way you said it like that that substrate of like mental distress and there are probably like various categories of that substrate but then there is that interactive process where um you're sort of the way you're expressing illness or whatever it is is like read by your community and once it's read interpreted by your community it sort of puts you on a certain path because you're responding to that too and like I think even to um to feel like seen is really validated so like if if you need to sort of make some adjustments so you fit that classification better and then you're sort of seen by your doctors as a more legible person that needs help I could see the how those shifts happen and I don't um yeah I don't like I definitely don't mean to say that it's not also like real biological illness but just that like we don't think as much about that sort of interactive dynamic that takes place once there's sort of an explanation or a story for that illness well the fact that you just use the word story reminds me that I I feel like I've neglected one of the core no no no don't which is that um you know you say that there are some stories that free us and some stories that trap us and that one of the things I love about this book is that way it's so nuanced it's neither an anti-psychiatry book saying that diagnoses are our traps and boxes and you know etc or nor is it uh you know psychiatrists are wonderful wise people here to help us and they they're they're their treatments can only do as good can you say something about the way that um our experience of distress is shaped by stories available to us and then how those stories can then become identities and start to trap us possibly um yeah and I guess stories was the word I came to because like I couldn't find the right word for what it is but like that moment where you like your illness sort of you weave like a narrative into like this illness sort of is going to determine my like this this idea that like you get a diagnosis and it starts to shape your sense of your own possibilities and it maybe starts to shape other people's understanding of sort of who you are and like um what you might do with your life and I think um then I also was interested in like the story that psychiatry has told over all these years in the sense that like um that there can only be one story at a given time I don't know if I'm totally answering your question but like I also think then there were all these stories that people were telling about themselves like through their own writing like many of the people that I wrote about were so invested and kind of like articulating what they had been through in the moment maybe because there was this feeling of like I think um it may be to like lose access to your own understanding of the experience once like someone else's interpretation has been placed on it and you sort of go trust yourself as like an authority on that experience. Yeah um I mean well I'm okay I'm gonna I want to talk with you so much more about this but um I want to transition now to audience questions because I'm looking at the document and see that there are a lot of great questions um here so um and again reminder uh it's not too late to submit a question if you want to um so the first question is uh from Kam Kidia who is a 20 I hope I pronounced that correctly 2023 fellow uh New America he uh says with Bapu you would lead to the role of colonialism and epistemic violence in shaping our stories of mental illness can you talk a little bit more about this link? And it was just so striking in India um that like the entire mental health system there was a sort of British a product of um colonial rule and I think like it was such an early instance of sort of transplanting British ideas of the self on to other people that there was this like sense of someone in this this like a quick next to pathologize expressions of religion and maybe a um failure to like appreciate that India had developed this like really robust way of understanding mental health and those kinds of strategies for a really long time were just like not seen as scientific and legitimate um and so I think even in Bapu's life the idea that like she could go further she could run away to a healing temple or she could be like behind bars in a hospital um there was sort of no possibility of those of like those methods intermingling and one of the interesting well one of the interesting things that you point out is that Bapu herself had a critique of that was sort of um of Indian psychiatry directly which is that if she had been a man those same behaviors would not have been pathologized in the same way. Right yeah I mean I was like shocked I when I interviewed her psychiatrist he was really old like 88 um but he just had and he was he was a Catholic Indian psychiatry a psychiatrist so he had like an interesting background but he was just so dismissive he like showed me really probably there was this plastic bag he'd like taken off all the charms and talismans that his patients had come in worried and he was like I take them off and I show them like if they're in this situation they don't need these and he just it was like this like joyful sense of like I am showing them what the truth is and this stuff didn't work. That was really shocking um an anonymous question um can you talk more about your experience covering resignation syndrome what advice would you have for people who write or read about culture-bound phenomena? I mean I was interested in when I when I would interview doctors the idea of suggesting that an illness like I think it's interesting that to tell someone an illness is cultural is seen as like such an insult um like that was and I never would have said that but like even when I would ask questions about like it's interesting that every the most of the patients who have resignation syndrome know someone who also had resignation syndrome and there was this like sort of I felt like that was a taboo question and like seen as a sort of anti-science question the idea that there was cultural influence um so wait I don't know if there's something I could say more about like the experience of writing about it but just that maybe like not um it definitely was conscious of not asking questions that implied that like the question the reality of someone's illness and I and I guess I didn't feel it was ever necessary like I can I could ask them if it's what they make of the fact that like multiple people know each other who have the illness but I don't think I was I think like even talking about any kind of illness like there is just this really like sensitivity about the idea that it's not like concrete and true and as if like it makes such a difference whether it's like I don't know I it's interesting to me that there is like such a distinction between something that's like real or not real even though either way like the person is totally suffering and like needing help and as though as you yourself pointed out with suicide um suicide is very much one person influencing another and no one thinks it's not real yeah it kind of reminds me of like this Indian psychiatrist I interviewed who said like it really bothered him when people would say like praying is not a biological and is a placebo effect it's not like a real intervention because he's like everything you do affects your biology so why is this like any less real than you know putting something into your body like it's still affecting your body another question from um and this is from uh Roxana Asgarian reading your thoughts on how illness and identity interplay I wondered about your thoughts on the explosion of trauma theory in the public consciousness I mean I would love to I find that so interesting and I've like always been looking for a way to write about that actually um like just anything that and I don't know what Roxana means by like a maybe there's something specific you're thinking about with trauma theory I guess I'm like speaking more generally about like how trauma has been like turned into this like object that like it's become so um I mean even like yet proving one's trauma or sort of in order to get like sometimes it's like there's a very real need like in order to get asylum you need to like show that you were traumatized but it's taken on this meaning um that I that feels like it's become more concrete than maybe like I don't know what what it actually means and I actually would love to hear what Roxana thinks but I like it's something that I've thought about but I don't have like uh coherent thoughts except that I think there's something weird going on with like the way that word has sort of become like the ultimate proof of wrong done um a question from Anonymous um and actually I'm glad that Anonymous asked this question because I was going to ask the same thing um can you talk about how the structure of the book came together um I mean you and I have talked at length about like you know many stories versus one story you know how you put them together I'd love to hear what you have to say about how you made that decision I mean that felt so hard to me because I I never had those concerns like I could just write a story and it could have its own point or ideas and I didn't have to think about how it related to other stories and I think um it I know that my editor had said early on that like I should think of the book as a prism and so like you're asking a series of questions and if you look at those questions from different angles you'll come to different answers and like that and then I think at some point I also started to be aware of the idea that like one of the freedoms of writing a book versus writing a story for the New Yorker for instance is that like when you're writing a story you're picking this one person story as representative of a larger theme or problem and like you know that in doing that it's not like fair or like it's it's just you're leaving out like so many different stories that probably conflict with that story um and so I liked there was something nice like when I realized at some point that like each chapter it was supposed to build on the previous chapter but it could also like throw the previous chapter into some degree of doubt so like there could be a way in which like a reader could feel destabilized like I okay I finished this chapter and I have this sense of how to answer these questions and then you go to the next chapter and you're like well maybe I was like too quick to reach that previous conclusion um and I think uh yeah I wanted I wanted the like the ideas to I think the the thing that my editor had said that was useful is like thinking of the ideas as a kind of character that like evolves from one chapter to the next um yeah I mean I could talk about this a lot more too because it was like a source of a lot of confusion and like retrying trying things out and them not working well can I ask you a sort of follow-up on that is like I mean having read your book twice now I feel like it couldn't have had any other form that this is definitely the best structure for it but um you wrote at some point in the book that at some point or other you considered making each of the stories that comprised your chapters the whole book the whole book about that person and I was wondering if you could just tell about talk about that decision and what would have been gained by making a book by writing a book only about one of these stories and what would have been lost we know what would have been lost because you just explained but what would have been gained um thank you for reading it twice by the way um but uh um well actually if I write another book I definitely want to just do one story like that would that would be just so much more pleasing in a lot of different ways but um because then there's like so much less pressure to I think like there's I think there's almost never it's very hard to find a story I think that like merits that length I did think Naomi like about telling Naomi's story as a book but it wouldn't have been it would have been about mental health but it would also have been about um like the child welfare system and the way that it had shaped like three generations of her family and so I guess it would have been a different story and that was the one that I really like I liked the idea of taking one person's story and then like branching out on different like showing different family members and how they sort of interpreted things differently um with so yeah how did I decide no I think that was more like I I find it so hard to know to ever feel like I just never wanted it to feel like I was blowing up a person's story to be at like some length this allowed me to feel like the story was at the length um I don't know but I also felt like I couldn't really like say the things I wanted to say about mental health if I just told one story. Yeah no that totally makes sense um well you mentioned a future book uh this is our next question from Katya Savchuk who says you've written about many fascinating subjects have you been tempted to expand any of your past articles into books and how have you decided whether to do so? I um I think it's only when there's like strands that I could keep following but I find it very hard to know like what first I find it really hard to come up with ideas that like ideas and second I find it hard to know to me the idea of like I think about random family by Adrienne Nicole LeBlanc as this like perfect example of something that justifies a book like it's just there would be no way to tell that story without a book and I guess the question I always have is like is there a way to tell that story in a shorter length and if so like um wouldn't that be the the better thing to do but maybe that's like some some stupid sort of magazine brain infernalization that I'm doing um so one I think one last question um one of the things I found fascinating was that you wrote about how this is this is I hope a historical uh note of yours um that western psychiatrists historically associated mental illness with civilization and thought that people who lived in less civilized societies would not become mentally ill and I wondered if there is any trace of that crazy idea still left if there's any sense as you read in sort of 19th century early 20th century novels that like mental illness could be thought of as a sign of sensitivity and refinement I mean I think so I think there's a sense of like even in the sum of the stigma that like the sort of psychiatry's failure to engage I mean I think like the legacy of feeling like people who are not civilized don't the psychiatry is like a field for the civilized and the refined and I think that legacy has shaped like both the stigma against using psychiatry like the fact that they would make assumptions like this um I mean I'm trying to think of like a specific example but it feels like a like stereotype that is still alive that like um the psychiatry likes a certain kind of patient who will be like who has certain ways of telling stories and and like sort of doesn't know how to deal with people who tell their story in language or in kind of using tropes that like don't conform to this very like overly internalized um I don't know there's just such a certain type of a psychiatric patient but it does make you question like why has a whole field been built so much around this one type of person yeah um I wish we could talk for so much longer and I hope we will get together and be able to do so um soon but uh we're out of time and so thank you so much Rachel um thank you thank you everyone for joining us and um just another reminder to do buy this book it is truly an extraordinary book and really you should read it okay thank you thank you for joining