Book Commentary: Lying on the Couch

‘Forget that crap about the patient not being ready for therapy! It’s the therapy that’s not ready for the patient. But you have to be bold and creative enough to fashion a new therapy for each patient’ (7)[1]

The therapeutic relationship, in all its many complex forms, dominates as the central theme of Irvin D. Yalom’s novel Lying on the Couch. The characters within the novel exist as a series of partnerships: therapists and patients, friends and lovers, lawyers and clients. Although Yalom focuses on challenging preconceived notions of therapy and the medical model, the concept of a therapeutic relationship is not limited to that which exists between the therapist and his patient. Instead, Yalom highlights the fact that any relationship can contain therapeutic dimensions and the reciprocity inherent in all forms of human interaction can turn anybody into a therapist. The characters within the novel interact in a series of reciprocal transmissions, from patient to therapist and back again. Yalom not only forces the reader to question the patient-therapist model but he also asks that therapy be perceived as a series of journeys made by two individuals together.

During an interview Dr. Trotter, a renegade and yet highly respected therapist, opens Dr. Ernest Lash’s mind to ‘flexibility’ in the patient-doctor relationship. Lash, who enjoys his profession immensely, wants to have a ‘real’ connection with his patients. He has been treating Justin, a man entrenched in an unhappy marriage, for years and Ernest feels that he has been unsuccessful in truly creating a viable rapport with Justin. When Justin ends his sessions, Ernest decides to respond candidly to his future patients’ personal questions in order to forge a truly honest relationship. In deciding to do this he violates many of the traditional rules of therapy. Yet with Dr. Trotter’s mantra in his head ‘My technique is to abandon technique. My technique is to tell the truth.’ Ernest embarks on an effort to transform his personal method of therapy, starting with Carol. This first relationship, between Dr. Trotter and Dr. Lash ultimately becomes the most significant. Ernest’s deviation from the psychiatric norm lays the framework for other deviations until the whole medical model and notions of therapy are put into question.  

The relationship between Carol and her therapist Ernest is deeply complex. Carol is Justin’s ex-wife and an attorney. She decides to begin seeing Ernest in an attempt to sabotage his practice. Although she did not love her husband, she feels the sting of his disloyalty deeply and she believes that Ernest played an important role in his leaving her. Carol has experienced a great deal of betrayal from the men in her life, her father abandoned her, her lovers denied her and her therapist in college took advantage of his position to repeatedly have sex with her. Carol enters Ernest’s office prepared to destroy him by manipulating him into a self-destructive romantic relationship. She creates a persona based almost entirely upon her own life experiences, with minor geographic changes so as to reduce the possibility of mistakes. Initially Carol believes she has the upper hand, because Ernest admits his attraction to her as a part of his honesty-policy. However, as time goes on, Carol becomes increasingly receptive to the therapy and begins to see the benefits in other aspects of her life. Ernest too, experiences benefits from this reciprocal relationship, but his attraction to Carol makes therapy conflicted and difficult. Yet he never acts on these attractions and ultimately the relationship he creates with Carol is based on a sense of mutual trust and understanding of a shared experience.

Ernest’s supervisor, Marshal Streider, is a highly ambitious therapist who aims to be the president of the American Psychiatric Association. At an APA meeting he denounces a fellow therapist, Seth Pande, for engaging in deviant practices with his patients.  As a result of this Streider becomes recognised as a certain kind of moral authority within the APA, and it certainly does not hurt his ambitions for presidency. Streider soon becomes involved with a wealthy, intelligent patient Peter Macondo who gives him insider information on investment opportunities. Motivated by greed, Streider invests with Macondo only to discover that the entire story was phoney and he has lost almost all of his investments. Not only that, but Streider has no one to confide in. He cannot trust any therapists who would eagerly spread the news of his downfall and illicit practices and his estranged wife pays him no attention. Desperate to catch Macondo, Streider hires Carol in the hopes that she might be able to give him some legal counsel that will redeem his financial situation. Streider takes advantage of Carol’s presence by relating his fears and anxieties to her. Carol slowly begins to take on the role of therapist; listening to him when no one else can and helping him deal with his situation. This role reversal highlights Yalom’s over all intention with the novel. The relationship between patient and doctor is not only fluid but also can be easily turned on its head. In fact, even the notion of a patient/doctor relationship becomes meaningless when the roles are so drastically reversed. In the course of her relationship with Streider, Carol even seeks advice from Ernest on how best to deal with her client. Again, each individual relationship is based on an ‘ebb and flow’ principle which challenges the notion of the medical model.

The relationships in Yalom’s work are deeply interconnected. Each individual within the story ends up affecting another in some fundamental, but often accidental, way. Yalom stresses the importance of a reciprocal relationship, because no human interaction can be entirely static. More importantly, however, Yalom asks: who is the therapist and what is his role? Does a therapist help the patient best by remaining untouchable? Or, as Ernest and Dr. Trotter believe, can the therapist create more long-lasting and penetrating change by exchanging and growing with the patient? Yalom asserts the latter conclusion, but in doing so he throws the old notions of therapy into uproar. He challenges the medical model not only with the patient-doctor relationship but he also democratises the notion of therapy. One does not become a therapist by virtue of being more ‘together’ than the rest of the population. In fact, Yalom asserts that anyone can be a therapist insofar as they are willing to put the time and effort into creating new experiences alongside another individual.