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Reviews for Lying on the Couch

Los Angeles Times Book Review, by Jonathan Kirsh

Stanford-based psychiatrist Dr. Irvin D. Yalom is an influential teacher and theorist of psychotherapy and author of scientific texts and popular works on the subject, including the best-selling “Love's Executioner” and “When Nietzsche Wept.” So Yalom brings to his latest work of fiction an authentic mastery of the techniques of psychotherapy and a real genius for showing the reader what is really going on inside the head of a psychiatrist while he or she is shrinking someone else.

The troubled hero of “Lying on the Couch” is a young psychiatrist and analyst-in-training named Ernest Lash whom we follow in to the labyrinth of the human mind where both psychiatrists and novelists ply their trades. And Lash is made to experience “that strange paradox of therapy” and novel writing: “The more unlawful, shameful, dark, ugly stuff you revealed, the more were your rewarded!”

The boogeyman who stalks the pages of Yalom's book is the shrink who sexually exploits his patients: “Therapist-patient sexual abuse is getting epidemic,” one character is made to say by way of announcing the theme of the book. “Therapists who sexually act out with their patients are invariably irresponsible and destructive.”

Yet Yalom allows us to see more than one therapist-patient sexual encounter in an equivocal light. Indeed, the dirty little secret at the heart of the book—the engine that drives the plot—is the notion that sex is a double-edged weapon that can be used by a disgruntled or disturbed patient against an otherwise innocent therapist.

Indeed, Lash himself is presented as a good-hearted guy who is honorable to a fault when it comes to his own sexuality. “The lady admires you—you act nobly—you don't get laid,” an old friend scolds Lash when he anguishes over a flirtation with a former patient. “The lady respects you even more and then goes home to bed with the vibrator. ”

Along the way, we are given an insider's view of the politics of psychoanalysis, the scandals that arise in the practice of psychotherapy, and, most intriguing of all, an intimate account of the innermost fears and longings of a psychiatrist at the very moemnt when he is supposed to be working out someone else's problems. Given the theme of “Lying on the Couch,” we are not surprised to find Dr. Lash stealing a look at his newest patient's lingerie—and we are shown how expertly the patient exploits the good doctor's weaker side for her own evil purposes.

“He was so far out on a limb, so far beyond what traditional technique decreed, so far beyond acceptable clinical practice,” Yalom writes of Lash at this moment of moral crisis, “that he knew he was entirely on his own—lost in the wilderness of wildcat therapy.”

Yalom invokes the novelist’s prerogative of making Dr. Lash’s alluring new patient—who turns out to be the villain of the piece—as detestable as possible. She is a crafty lawyer, a casual adulterer, a faithless friend. Above all, she is depicted as a cynical and calculating seductress with the worst possible motives toward the men in her life, not excluding the psychiatrist whom she has chosen as her victim.

The rule of confidentiality that applies to book reviewers no less than psychotherapists prevents me from disclosing exactly how Yalom works out the cat’s cradle of plots and subplots. But he manages it with such panache that all of his sleight of hand, as a novelist and a psychiatrist, will be forgiven.

American Journal of Psychiatry Review, Dec. 1996, by Glen Gabbard

Early in his career as a psychoanalyst, Freud received a referral from the eminent Viennese gynecologist Rudolf Chrobak. Frustrated with the treatment-resistant nature of his patient’s hysterical symptoms, Chrobak observed that the sole prescription in such a case was one they could not order “penis normalis dosim repetatur.”

Freud listened patiently to his colleague but could only shake his head at his friend’s cynicism. Unfortunately, this historical episode was not the last time that a misguided clinician would endorse the notion of magic copulatory healing. Indeed, in case after case of psychotherapists who become sexually involved with their patients, a similar fantasy that sex will somehow cure the patient is often just underneath the surface. Patients, of course, may harbor the same fantasy.

The protagonist of this new novel by Irvin Yalom, Dr. Ernest Lash, confronts this idea in the opening chapter. Ernest is a young psychiatrist involved in an ethics investigation of a much esteemed senior colleague who made a Faustian bargain with an irresistible female patient, who, on the surface, appears to have benefited from a sexual boundary violation while her therapist’s career was destroyed by it. As Yalom demonstrated in his first novel, When Nietzsche Wept he is a master storyteller. He skillfully constructs a narrative that allows the lives of several therapists, patients, and supervisors to become coincidentally, but believably, intertwined. One of the characters, Carol, poses as a patient with the sole purpose of seducing Ernest and wreaking havoc on his professional career. Startling twists and turns in the story line delight the reader and provide an absorbing and thoroughly enjoyable read.

As the title suggests, deception in the therapeutic setting is a major theme in Yalom’s novel. Therapists assume honesty from their patients and therefore have an inherent gullibility that can be exploited by the unscrupulous. Moreover, the author reminds us that our own vanity may make us particularly vulnerable.

Yalom has a knack for capturing authentic-sounding dialogue between therapist and patient. As readers of his previous contributions would expect, there is an ongoing tension between the psychoanalytic view of the therapeutic encounter and the existential perspective. Psychoanalysts tend to be portrayed as caricatures who serve as foils for Ernest, who is more existentially oriented. In one turn of events that is too complex to explain in a brief review, a senior psychoanalyst appears to benefit enormously from existential psychotherapy provided by a lawyer! Of course, the writer of fiction is not bound by the constraints of reality. Nevertheless, Yalom clearly has high regard for much that is psychoanalytic, and he compellingly depicts dilemmas for the therapist that characterize contemporary psychoanalytic therapy, including those regarding deprivation versus gratification, interpretation versus relationship, and self-disclosure versus anonymity.

The centerpiece of the novel is Ernest’s decision to be thoroughly authentic and honest in his therapy of Carol. In an experiment reminiscent of Ferenczi’s mutual analysis, he agrees to answer all of his patient’s questions and expose himself to the same degree as his patient does. In charting the course of this treatment, the authorial voice becomes a bit murky. Yalom seems to re-emphasize the value of authentic self-disclosure by the therapist as an instrumental part of Carol’s improvement in treatment, but much of the actual therapy material suggests that the therapist’s insights into Carol’s unconscious patterns are much more useful to her than his self-revelations.

Ernest recognizes the necessity-from both clinical and ethical points of view to draw a dear line for the patient regarding the violation of sexual boundaries. The grayer area involves the difficulty in discerning which self-disclosures are constructive and useful to the therapy rather than a misuse of the patients time and money. One could argue, of course, that everything therapists say reveals something about themselves. But the challenge is how things are disclosed and what information is strategically kept undisclosed. To complicate matters further, the optimal level of self-disclosure varies from patient to patient. While absolute or rigid guidelines may bring a temporary sense of comfort and certainty, they will seriously limit the range of patients that a therapist can treat. Yalom vividly depicts the double-edged nature of self-disclosure, it may serve as the first stop down the slippery slope to serious sexual boundary violations, or it may open up an analytic space that makes a difficult patient more accessible to therapeutic interventions. The challenge of being authentic but therapeutic is a formidable one and recalls Freud’s 1915 comment that the analyst must pursue a course for which there is no model in real life.

Every therapist who reads this book will identify with the struggles of its protagonist while having a marvelous time with a colorful cast of characters who come alive in the hands of a superb craftsman. The novel is written well enough that it can also be recommended to educated readers outside the mental health professions. With this work, Yalom has established himself in a unique position in our field, a respected psychiatrist who has made the transition to successful novelist and earned well-deserved regard in both spheres.

Lying on the Couch: A Novel
Journal of the American Medical Association
January 1, 1997 - Vol 277, No 1
Sheppard Pratt Health System
Baltimore, MD

Psychiatry is a vital part of medicine. As healing professionals, psychiatrists face many challenges. Managed care has intruded on the privacy of the doctor-patient relationship and disrupted continuing care. Modern psychopharmacology has brought into question the need and efficacy of the talking treatment, that is, psychotherapy. The many therapeutic schools foster bitter competition among practitioners, both medical and nonmedical. Highly publicized cases of therapist-patient sex, recovered memory suits, and unethical behavior tarnish the literally thousands of hours of work of diligent, honest therapists and patients. Psychotherapy, 100 years after the invention of psychoanalysis, is as controversial today as it was in late 19th century Vienna. How much is science? How much is art? How much is invention? How much is chicanery and manipulation? All are issues in today’s popular imagination. Perhaps the biggest challenge comes from our patients and how we provide therapy for their suffering.

And what do we know to be true in psychotherapy? How does it work? Why is it called “the impossible profession”? And how should we define and enforce the critical boundaries between doctor and patient that allow therapy to proceed ethically but sometimes get in the way of enduring personal change?

In Lying on the Couch, Irvin Yalom, MD, a psychiatrist who has written both extensive nonfiction on what heals in psychotherapy and a previous novel, When Nietzsche Wept, has turned again to fiction to portray these issues in an intense, immediate, and entertaining way.

In this moral tale, we meet two San Francisco psychotherapists who approach patient care in very different fashions. Ernest Lash is a former psychopharmacologist in his late thirties who conducts psychotherapy in an uncoventional and existential manner. Marshal Streider is a traditional, orthodox psychoanalyst who is well situated in the psychoanalytic establishment of San Francisco.

Dr. Streider is Dr. Lash’s supervisor, and although Lash appreciates many of the finer points of supervision, he rebels against his mentor’s orthodoxy by experimenting with a more intimate type of therapy that demands a genuine and authentic relationship between patient and therapist. Unfortunately for Lash, he chooses to try his direct, truthful approach on a new patient: a woman who is out for revenge for what she perceives to be Lash’s meddling in her marriage, by encouraging her husband, a patient in treatment, to leave her, leading to a bitter divorce. Carol comes to therapy posing as a patient, with an agenda to sexually seduce Lash and destroy his career.

Streider has his own issues with money and status and is undone by a new patient, Peter, who tries to convince him to invest in one of his new businesses - another seduction and of equal ethical concern.

These two young psychiatrists as wounded healers are portrayed in disturbingly recognizable encounters that reveal what goes on in the minds of psychtherapists as they try to help their patients. Few books are so explicit about the thought process of the psychotherapist in therapy. Few confront the issues of what happens between doctor and patient and the boundaries or rules that, if not abided by, could lead to harm to both patient and therapist alike.

One of the most disturbing aspects of this novel is that the patients do not tell the truth. They literally “lie on the couch,” and both Lash and Streider are shown to be extremely vulnerable to the dishonest communications of their patients, despite extensive training and understanding, a risk in all therapy.

Lying on the Couch is a satiric novel, exposing many of the foibles of psychoanalysis and existential psychotherapy. It is also about ethics - the so-called slippery slope of boundary violations as therapists are tempted to violate codes of behavior. It is a well-written tale of sex, money, confidentiality, managed care, and false memories, confronting the reader to think about these issues from the more immediate view point of the characters in the novel. Humor relieves the tensions of the conflict of life vs therapy.

For psychiatric clinicians, this book is a fascinating page-turner, difficult to put down. In addition to its being a good yarn, there is a lot to learn about technique and ethical boundaries. The ending is too sugar-coated for my taste, a neat, cut-and-dried redemptive series of solutions that undercut the messy realism of the issues posed.

Yalom’s new novel extols the efforts of therapists to reach out to patients in genuine and authentic ways, and at the same time to be self-critical and humble in the face of uncertainty and human intimacy. It is an enjoyable and informative excursion into the mysterious realm of the psychotherapist and patient.