BOOK REVIEW---LYING ON THE COUCH BY IRVIN YALOM MD

This is an enjoyable and thought-provoking new novel from a psychiatrist who knows how to spin a yarn. His previous novels were Love's Executioner & Other Tales of Psychotherapy" (1989) and "When Nietzsche Wept" (1992). The latter was a winner of the Commonwealth Award for Best Fiction. Yalom is also known for his "Every Day Gets a Little Closer" and his classic texts, "Theory and Practice of Group Psychology" and "Existential Psychotherapy".

He is a professor of psychiatry at Stanford University and lives in Palo Alto, California. I can only wonder how his colleagues in northern California relate to some of the characters, plot and issues of this fascinating and spellbinding book. Yalom presumes to relate how psychiatrists and psychoanalysts actually think and feel, and my guess is that while many real practitioners would not identify with the characters portrayed many others would. In order to get through the book, the reader must suspend reality and get caught up in YalomÕs fantastic plot. What would it be like to be the target of a vengeful woman lawyer, who blames you for her husband leaving her for a younger woman, and who is intent to destroy you by seducing you?

Ordinarily, I do not go through a novel relentlessly, cover to cover, spending all my spare time on it. The last time I did so was Pat Conroy's "The Prince of Tides", which was more psychologically sound and believable, and better written. But Yalom is no slouch. He caught me up because I could relate to the protagonist, Ernest Lash, who is a young psychiatrist trained in neuroscience to be an efficient psychopharmacologist. Just as I did, he quickly found out that real psychiatric patients rarely are helped by ingesting psychotropic chemicals alone. There is an essential doctor-patient relationship without which significant, long-lasting benefit rarely occurs.

Lash has to learn more about psychotherapy after he is out in practice, and seeks the supervisory assistance of the novelÕs other protagonist, the foil for classical, traditional psychoanalysis. This is Marshal Streider, a veritable superman, as he is a powerfully built former football linebacker, and leading exponent of contemporary psychoanalysis. He is rigid, competitive and unrelenting in his adherence to the trendy 'boundaries'. He defends traditional psychoanalysis, the couch, free-association, dream analysis, the objective, detached, anonymous position of the analyst, the worship of the accurate and timely interpretation.

The younger, inexperienced psychotherapist is in awe of Streider, but intuitively feels that the traditional couch method is outdated, inefficient and ineffective. He feels the analystÕs objective detachment and authoritarian position is dishonest and works against a real relationship. He wants a dialog instead of a monolog, face-to-face instead of the couch, honesty and spontaneity instead of a calculated reserve. He finds thatÕs just the way he is, he wants to be more relaxed and comfortable in a more human, egalitarian relationship. He was taught by SeymourTrotter, a maverick old-timer, who he had to interview for the ethics committee. Seymour had some wild ideas and practices, and was booted out of the analytic society, but the old man said some things in his defense that stuck with the young psychiatrist.

The old man said that drugs were for the birds, that the diagnostic and statistical manual was a sham and a farce, that every patient was different and defied pidgeon-holing, that a unique psychotherapy had to be created for each patient, as each human being and relationship was unique, the doctor as well as the patient.

But the old man crossed some boundaries and was punished for it. He went over the line. But where was the line? Our work is full of gray areas and it seems an impossible profession, but the thread through the novel is that LashÕs openness, vulnerability, humility, egalitarianism and honesty worked, while Streider's rigidity and orthodoxy did not. Yalom seems to be telling us that the old methods of the analytic institute did not bring about real thoroughgoing analyses, and that some of these certified, card-carrying, training-analysts had tunnel vision into the depths, and were not real ÔmenschenkennerÕ. The reader could easily get the idea that many training analysts hid behind their silences and anonymity, and actually feared to make contact on a real, human basis with their analysands, and as a result, the patient never got to resolve their basic, underlying interpersonal issues.

It is as if Yalom were calling to us to beware of those who seem to know-it-all, who claim a vision beyond the ken of ordinary mortals. Could it be that the certainty that you are right is a defect of character? American analytic institutes are not known for their careful study of Wilhelm Reich. Like Trotter, Reich could be dismissed as acting-out and crazy. But who can deny the impregnable barrier of character-armor? Have we really developed techniques to analyze and work through the multiple layers of ego-syntonic characterologic defenses that sometimes takes the form of intellectual arrogance?

Consider this from Tolstoy:

ÒI know that most men-- not only those considered clever, but even those who are clever and capable of understanding the most difficult scientific, mathematical or philosophic problems--- can seldom discern even the simplest and most obvious truth, if it be such as obliges them to admit the falsity of conclusions they have formed, perhaps with much difficulty--- conclusions of which they are proud, which they have taught to others, and on which they have built their lives. (1898)

A few years ago, at a symposium on long analyses given locally, Merton Gill was heard to say that in his venerable experience, what we call a thorough analysis is still just scratching the surface. And more recently, Owen Renik, like Yalom of northern California vintage, gave the older generation of training analysts in Michigan a run for their money in his talk, ÒGetting Real in PsychoanalysisÓ. He recounted a case in which his getting real with a patient not only prevented a tendency toward regressive withdrawal, but led to insight and change in the short space of a week. Older analysts preferred a more traditional technique which they felt led to deeper depths. Getting real was dangerously superficial. Renik successfully defended his idea that analyst and analysand must pay more attention to external, objective reality, going against the idea that analyzing the transference-neurosis irrespective of external considerations, is the be-all and end-all.

There are many roads to Rome, and contemporary psychoanalysis is searching for ways out of the desultory reputation it has inherited, somewhat deservedly. YalomÕs book indirectly and ingeniously leads the sophisticated reader, whether it be analyst or analysand, psychiatrist or patient, psychologist or client, to think deeply about the real issues that effect psychoanalysis today.

The story leads from one dark and lonely struggle to another, from one tortured relationship to another, with wonderful ironic happenings. It unfolds and the plot thickens, just like a therapy case, and we are pessimistic about a happy ending. It seems there is no way out of the darkness. There are twists and turns, shocking realizations and stunning insights which propel the reader from the first page to the last. When one finally gets to the last page and the last line, there is an ÔahÕ of positive hope for the main characters and for the future of psychoanalysis.

By Victor Bloom MD

Dr. Bloom is Clinical Associate Professor of Psychiatry, Wayne State University School of Medicine. (email: vbloom@comcast.net)