Wally Lamb’s highly successful second novel, I Know This Much Is True, like his first, She’s Come Undone(1) examines a family’s struggle with mental illness and treatment. Both books are important because popular literature, film, and art have a significant impact on how people outside mental health view mental illness and those who endeavor to treat it. One Flew Over the Cuckoo’s Nest, for example, as a book (2) and a film, has had a lasting impact on the public’s perception of mental hospitals, ECT, and psychiatric nurses.

Lamb’s focus on mental illness is apparent from the outset. In the opening pages, a central character amputates his hand while on pass from the local psychiatric hospital. With that baptism, the story thrusts the reader into the lives of Thomas and Dominick Birdsey, identical twin brothers born to a single mother and raised in a 1950s Connecticut Naval town. Thomas has schizophrenia, a reality that becomes apparent to the family during his first year of college. In real time, the book covers a short period, from the mutilation episode through several months of Thomas’ inevitable commitment. However, the use of flashbacks and other clever devices (a rediscovered grandfather’s diary is beautifully woven into the story line) allows the story to begin many years before the twins’ birth. This history provides a rich contextual background for the book’s present events and supplies the psychological underpinnings of the main characters.

In addition to schizophrenia, the book examines posttraumatic stress disorder (PTSD). Written in the first person by the twin who is not afflicted with schizophrenia, the story recounts a jarring history of multigenerational childhood abuse. Dominick’s memories, coupled with tragedies in his adult life, cause him to develop classic PTSD symptoms that profoundly affect his ability to function. Perhaps the book’s greatest strength is bringing alive how trauma affects individuals and families in complex and sometimes unpredictable ways. Dominick’s struggle with his own wellness, and the expectation that he too could eventually develop schizophrenia, is developed in a realistic and compassionate fashion.

Sadly, despite extensive description and discussion of the forensic treatment setting, Thomas’ psychiatrist is mentioned only in the most peripheral fashion. Rather, the psychiatric establishment is portrayed as a politically motivated and unsympathetic monolith whose main function appears to be locking patients away. The two mental health provider characters who are developed, a social worker and a psychologist, are both portrayed as empathic and skilled patient advocates. Boundary blurring abounds, as it does in many recent portrayals of mental health treatment. The psychologist ends up treating the nonhospitalized brother, and the social worker has him over to her house for dinner.

This is a moving and intense book that describes the experience of those afflicted with mental illness and the families who love them in vivid and unforgettable detail. Lamb explores both psychological and biological contributors to the disease process and presents treatment as appropriate and useful. I Know This Much Is True is, however, unrealistic in many ways and will likely add to a broad literature already in existence that distorts real-life treatment issues and the mental health providers who struggle with them.