I was very favorably impressed with Neugeboren's previous book, Imagining Robert (reviewed in Metapsychology July 1998) and so I looked forward to reading Transforming Madness. I'm very pleased to report that I was not disappointed. Neugeboren's writing style draws the reader in, chronicling his own exploration of the mental health system, and his search for help for his brother Robert.
Robert has a serious mental illness. His diagnosis is bipolar mood disorder. He's been in and out of mental hospitals for decades. He has had all sorts of treatments, many of them with very unpleasant side effects. One of the themes of Imagining Robert is how amazingly resilient Robert is, and how he keeps a sense of humor and hope despite all he's been through. Neugeboren is often highly critical of the care, or lack of it, that Robert has been given. He's critical of individual psychiatrists and therapists, and he's critical of the mental health system as a whole.
The message of Transforming Madness is, however, a hopeful one. It is that schizophrenia, manic depression and other serious mental illnesses are in fact highly treatable. They may not be curable, but we should not think that they mean the person with the mental illness has to be written off. Given the right sort of treatment, most people with such disorders can really be helped. The shame of it is that so few are getting the help that they could be.
This book is about what kinds of treatment have been overlooked. Neugeboren continues his story of Robert, and his move from one hospital to a different one where he gets much better care. There is not a sudden change in Robert's condition, but he does clearly improve over time. The book doesn't end with Robert completely better, but there is a hope that he will continue to improve his life.
Robert is not the main figure here, however. Rather, the book more general in its scope, setting out a range of different programs that have been set up in the last decade or so. Neugeboren avoids making his discoveries read like a textbook by writing almost in the style of a personal journal. He describes the characters he meets, and adds his personal observations along the way. Sometimes he reconstructs his train of thought, associating from one idea to another, reporting it almost as the kind of free association one does in therapy.
But there is nothing casual about the ideas that Neugeboren presents. He has done a great deal of research, which combines with his decades of experience with his brother's treatment to make a very strong case that people with severe mental illness need much more social support, and often benefit from psychotherapy. Of course the therapy doesn't cure the illness, but it helps the patient deal with the illness.
In a review of Imaginging Robert, in the prestigious American Journal of Psychiatry, the well known psychiatrist E. Fuller Torrey is somewhat defensive about psychiatry and is critical of Neugeboren, ridiculing the idea that psychoanalytic psychotherapy could help Robert. This almost deliberate misunderstanding of Neugeboren was intellectually lazy, and Transforming Madness makes even clearer what Neugeboren has in mind, leaving no room for Torrey's objections. Torrey of course knows well that there is a major difference between psychoanalysis and psychotherapy, yet he treats them as equivalent in his review. Neugeboren is not suggesting that people with severe mental illnesses will be cured or even merely helped by the old fashioned psychoanalytic process of lying down for an hour a day on a couch, with a silent psychoanalyst sitting behind, spending years exploring their unconscious motivations. What he is arguing is that patients benefit from emotional support, with a professional ready to act as an advocate for patients rather than treat them as if they are the problem. He thinks it is important that mental patients should be encouraged to be as autonomous as possible. It's well-known that people living in institutions become so accustomed to them that they end up unable to live anywhere else. (This isn't true just of mental hospitals and prisons: I see it also in higher education!) So finding the right medication is very important when treating serious mental illness, but it won't by itself solve all a patient's problems.
The majority of this book is taken up with Jay meeting's with extraordinary individuals, many of whom have learned to cope with mental illness, who devote their lives to helping others. He starts out attending an award ceremony sponsored by Boston University's Center for Psychiatric Rehabilitation. The students graduating from their program all have long-term histories of mental illness, yet have managed to create families and hold down rewarding jobs. He later meets with Moe Armstrong, now of Vinfen Corporation. Moe also suffers from mental illness, is a passionate advocate for the mentally ill, and manages to be incredibly productive. We meet many such figures throughout the book, although Moe is especially important, and crops up several times throughout the story.
I found that Transforming Madness changed my understanding of major mental illness. Although Neugeboren doesn't present any new scientific data, and is neither a psychiatrist nor a psychological researcher, he manages to bring facts and ideas together with great force. I already knew that there are people diagnosed with severe mental illness who manage to live as close to a normal life as most of us can, that the symptoms of mental illnesses can decrease over time, sometimes even without medication and especially with medication, and that social support is crucial as a way of supporting people with mental illnesses. Yet Transforming Madness managed to shift what I already knew into a new perspective, putting those facts in the foreground. This makes me both more hopeful about mental illness and more angry when people who could benefit from good treatment don't get it. Neugeboren has written an important book which deserves a wide readership.