Lying on the Couch by Irvin Yalom: a Critical Examination

“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.”

~ Irvin Yalom, Lying on the Couch

Introduction

Irvin Yalom’s Lying on the Couch is a work of fiction that extends beyond its narrative to extend moral, ethical, and professional tidbits of wisdom for the working psychologist and psychiatrist. It is, after all, a work of satire, and works toward commenting on the doctor-patient relationship in psychiatry and clinical psychology. The entire book presents the idea that this relationship is simultaneously more complicated and more personal than the academic point of view, since therapy is by its very nature a deeply personal experience involving two people. The book is far from a celebration of psychiatry as a profession; instead, it works to point out the ways in which the profession falls short on a moral and ethical level. More specifically, the book deals with specific ways in which therapists and psychiatrists can violate a moral and ethical code in their relationships with patients. In order to address how the novel relates to real life, this discussion paper discusses three specific ethical violations in the book and how they relate to the American Counseling Association’s (ACA) Code of Ethics. The first violation, or dilemma, is the maxim that runs as a theme throughout the novel: “My technique is to abandon all technique (Yalom 7). This causes a great deal of confusion for one of the main characters, and directly violates ACA ethics. The second violation is Streider’s decision to use inside information gained from wealthy patients to invest in the market. The final violation is Ernest’s personal interest in the relationship between Justin and Carol, and the fact that he gains pleasure from their split up. While there are many other violations that the novel deals with, these are presented as direct violations of ACA standards. First, it is worthwhile to note that while Yalom’s book may be a work of fiction, it presents a sort of case study in ethics and morals within the profession of psychiatry. As one commentary on the book says, “Fiction in literature can assist in the analysis of therapeutic and ethical dilemmas in psychotherapy…the in-depth exploration of a fictional case such as this one allows therapists to critically evaluate the decisions that underlie problems in the therapeutic encounter” (Rubin, 2001, 146). With this in mind, the subsequent discussion addresses several of the ethical violations presented in Yalom’s book, and how they relate to ACA guidelines.

Ethical Struggles

The first is the maxim presented by Dr. Seymour Trotter, who states that his technique “is to abandon all technique” (Yalom 7). While this may not appear to be an ethical issue at first, the approach essentially does away with the idea that psychiatry can be systemized or institutionalized so as to maintain the autonomy of patients and trustworthiness of psychiatrists. In this way, the maxim essentially violates the first section of the ACA code: A.1.a states that “the primary responsibility of counselors is to respect the dignity and promote the welfare of clients” (ACA 4). The action also violates a subsequent section of the ACA ethics code, which states that counselors “have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies” (ACA 8). The attitude by Trotter therefore violates the ACA by ignoring the idea that it is his primary responsibility to provide respect and welfare of the clients by using proven techniques, instead substituting this for his own experimental interests. This also violates the fifth principle outlined by Kitchener: “One should keep promises, tell the truth, be loyal, and maintain respect and civility in human discourse” (Kitchener 55). Clearly, this goes out the window if one is allowed to take an individual, experimental view on technique and the ramifications are clear: a less professional approach by the doctor, and a less effective and even damaging experience by the patient. The justification given by the character – namely, that this approach allows the doctor to better relate to his patients – does not hold up when one considers the damage to ethical standards in the profession as a whole. Applying this situation to a practice setting, in clinical psychology and talking therapy, I would respond to the doctor’s claim to technique by challenging him to think through how his actions and approach may affect his clients in the long term, rather than only thinking of the short term ‘benefit’ of getting clients to talk.

The second ethical issue presented in the novel is Streider’s decision to utilize the knowledge he gains from wealthy clients to invest “intelligently” in order to make a larger return. This is simply a psychiatric twist on insider training, and certainly violates the ACA ethical code. Most specifically, this decision violates section C.6.d of the ACA ethical code, which simply states: “Counselors do not exploit others in their professional relationships” (ACA 10). This may seem to be an overarching, generalized guideline at first, but its applicability is clear. Even if Streider does not think of it as exploitation, he is exploiting his clients by utilizing the information they provide him (most importantly, information provided in confidence) for personal financial gain. This also violated Kitchener’s fifth principle of decision making in psychology, since it betrays trust: “Only in so far as we sustain faithfulness can we expect to be seen as being trustworthy” (Kitchener 55). The ramification of this decision is, at the very least, the ethical compromise of the psychiatrist, as he has broken the client’s trust. At the worst, it could come back to damage the client’s professional reputation, position at work, and even mental health. Thankfully, it seems that Streider struggles with this ethical dilemma; however, his response to actually invest is indefensible, since it violates the designed relationship of counselor to patient. In a practice setting, such as clinical psychology, I would find this decision to be a offense requiring termination, and even consider taking it further by removing the perpetrator from clinical practice. A practitioner in this case would have violated the trust of both the patient and the practice of clinical psychology.

The final ethical dilemma present in the book is the more overarching issue of Ernest’s personal interest in the relationship between Justin and Carol, his pleasure from their split up, and finally his interest in Carol later on. This runs more as a theme through the book, and represents an important deviation from the ethical standards laid out by the ACA: section A.4.b states that “counselors are aware of – and avoid imposing – their own values, attitudes, beliefs, and behaviors” (ACA 5). Ernest violated this aspect of the ethical code on two fronts: first, he imposed his own attitude toward his clients’ relationship onto their outcome and, second, he took it a step further when Carol returned to seduce him. This also violated the first moral principle laid out by Kitchener (the respect of autonomy), who states that “individuals have the right to decide how they live their lives” (Kitchener 43). This sort of David and Bathsheba situation clearly violates this autonomy. Ernest’s justification for this situation, that the relationship between a patient and doctor is “flexible” is weak at best, since it ignores essentially all professional standards, including the very explicit guideline of avoiding romantic, sexual, or even overly personal relationships with clients. In a practice situation, I would also consider this to be an offense that requires termination at the very least, and most likely a more formal complaint to remove the offender from practice altogether.