Dr. Young Replies

To the Editor: I am pleased to reply to Dr. Rosen’s thoughtful comments on my review of Lamb’s I Know This Much Is True. I agree that this book reveals many truths about mental health practice in the current environment. As he points out, the role of effective psychotherapy practice and teaching has diminished in importance for many psychiatrists.

However, while Lamb’s novel may reflect this truth, it also provides a decidedly inaccurate portrayal of modern psychiatry and psychiatrists. Indeed, the blurring of roles between patients and therapists has been a popular theme in books and cinema for some time. This trend predates managed care and the changes in our practice environment by many years. An excellent example is Conroy’s Prince of Tides (1), published in 1986 (quite early in the managed care era in American psychiatry). In this novel, in which a psychotherapeutic relationship is also central, numerous boundaries between patient and therapist become blurred. Their relationship evolves into a sexual one. The clear message is that the relationship’s intimacy, both emotional and sexual, is what heals the patient. Gabbard and Gabbard (2) documented numerous other examples from the world of cinema. The truth reflected in these examples, including I Know This Much Is True, may be the age-old fantasy of the patient who wishes to break through the confines of the therapeutic alliance and enjoin the therapist in a “real” relationship.

My problems with Lamb stem from his overly dramatized descriptions, especially of the forensic facility. The hospital is depicted as an out-of-control, nonempathic, and dangerous place. For example, on the night of Thomas’s admission, a security officer assaults his brother. Later the brother uses this incident to blackmail the staff into providing freedoms for his brother. Having worked in a number of forensic settings, I found this depiction to be unfair and inaccurate.

Nonetheless, Lamb has crafted a wonderful novel that depicts struggles between siblings and generations in a unique and often moving way. I just wish the psychiatrists had been portrayed with a bit more empathy and realism. Current and future patients will read this book. To some extent, we have a duty to speak up and educate them about what is real and what truly is fiction.