Lying on the Couch: A Novel, by Irvin D. Yalom

This grand satire on psychotherapy came out in 2014. It focuses on the lives of a few interlinked psychotherapists in San Francisco.

The principle thread of the book is transference and countertransference, the sometimes erotic attachment that can build between a patient and therapist or vice versa. The book opens with one therapist talking to another about an incident in which a beautiful woman patient claimed to have fallen in love with him. The therapist, at 71, decided to accept the woman’s passion and reciprocate as a part of therapy. The therapist is now facing expulsion by the local institute of psychotherapy.

The novel then follows the therapist listening to this story, Ernest, as well as two others through their relationships with patients and peers. Ernest is targeted by a woman who was married to a man Ernest had been treating and has now demanded a divorce. She tries to entrap Ernest in a sexual relationship. Young Seymour is a new therapist still being supervised who believes in trying to bring new and creative methods to a profession that accepts new ideas slowly. Marshal is a therapist who is obsessed with his income and investments and risks his standing when he accepts an investment tip from a patient.

It’s an interesting portrait of a profession and it becomes clear that, for all the various concerns the doctors may have, one that seldom comes up is whether a patient is being helped. Trained in methods that can take years many see their incomes endangered by insurance companies who limit visits to 5 or 6 a year. Some have given up therapy to do medication management. In all cases they find daily challenges to their oaths and integrity through daily interaction with people at their most emotionally vulnerable.

To add to these stresses are the politics of any profession in seeking more prestige than peers, either through income or position in professional associations. Because of the limits of insurance and the cost of therapy it has, in most cases, become a treatment for the rich, making some therapists feel out of place with or envious of the people they treat.

At times it’s a sexy book, at other times it reads like a crime story or a revenge tale as each doctor faces various demons in himself and his patients. The book as a whole is a hilarious portrait of people working within a field that is torn between modern medicine and its roots in Freud and Jung. It’s sophisticated and perfectly paced and one of those books that book clubs are made to devour.