Developing Courage on the Couch : LOVE’S EXECUTIONER AND OTHER TALES OF PSYCHOTHERAPY <i> by Irvin Yalom MD (Basic Books: $19.95; 288 pp.) </i>

Irvin Yalom is a psychiatrist deeply familiar with the vicissitudes of clinical practice, and author of a number of books on psychotherapy. Philosophically committed to “existential psychotherapy” (he has published a book on the subject), Yalom believes that the “primal stuff” of psychotherapy is what he calls “existence pain,” and not repressed instinctual urges or the painfully unresolved moments of events of an individual’s earlier life. The questions that haunt his patients are the very ones posed by Gauguin in his famous triptych: “Where Do We Come From? What Are We? Where Are We Going?”

During the course of his clinical work with patients, Yalom has come to recognize four “givens” especially relevant to psychotherapy: the inevitability of death for each of us; the freedom we possess to make what we will of our lives; our basic aloneness, and the lack of any real, sustaining meaning to life. It is these essential facts, as he sees them, with which his patients wrestle, and more often than not have come to a painful, deeply unsatisfying truce with. Part of his task, as a psychotherapist, is to assist in “dis-illusioning” his patients; to help them to accept these “facts” of existence. “Though the fact of death destroys us,” he is inspired by one patient to write, “the idea of death may save us.”

“Love’s Executioner and Other Tales of Psychotherapy” is a collection of case histories derived from Yalom’s work with 10 of his patients, the best of which read as finely wrought short stories. With them he breathes life into his philosophical and clinical preoccupations.

A psychiatrist with an aversion to overly rigid theoretical or methodological constraints, Yalom has wisely chosen to transmute the daunting, private struggles waged weekly (occasionally more often) in the psychotherapeutic relationship into these illuminating “tales.” In so doing, he sidesteps much of the dreary and often banal language of his field. These stories, some more sharply etched and revealing than others, all harbor a premise long familiar to the novelist and short story writer: namely, that a given life can be illuminated and to some degree shared, yet it can never be fully explained. Each life retains a measure of mystery that ultimately can only be appreciated and respected. “The soul of man is (indeed) a far country,” as D. M. Thomas observed in “The White Hotel.”

Aside from illustrating the ways in which “existence pain” is woven into the lives, and symptoms, of Yalom’s patients, these stories are essentially a meditation on character as it is revealed in the relationship with the therapist. (It is invigorating to see a psychiatrist turn his attention to character, as opposed to character disorders.)

Many of these stories manage, through vivid dialogue and a keen attention to the myriad details that comprise the fabric of a life, to reveal a great deal about these individual men and women. Yalom in this way underscores what he sees as the banality and limitations of the standard diagnostic approach to personality. “I . . . marvel that anyone can take diagnosis seriously, that it can ever be considered more than a simple cluster of symptoms and behavioral traits. . . . If we relate to people believing that we can categorize them, we will neither identify nor nurture the parts, the vital parts, of the other that transcends category. The enabling relationship always assumes that the other is never fully knowable.” With these stories, Yalom seeks to replace categories that restrict our vision, with metaphors (or one should say, different metaphors, since a diagnosis is a metaphor of sorts) that expand our vision.

Certain of these tales are gems of compression, offering vivid and detailed portraits. The title story, one of the best, “Love’s Executioner,” introduces us to Thelma, desperately seeking relief from an incapacitating love obsession. Here is Yalom’s initial encounter with her: “Thelma, in the opening minutes of our first interview, told me that she was hopelessly, tragically in love, and I never hesitated, not for one moment, to accept her for treatment. Everything I saw in my first glance--her wrinkled 70-year-old face with that senile chin tremor; her thinning, peroxided, unkempt yellow hair; her emaciated blue-veined hands--told me she had to be mistaken, that she could not be in love. How could love ever choose to ravage that frail, totering old body, or to house itself in that shapeless polyester jogging suit?”

From that lucid snapshot we are led down the path of Thelma’s obsession. It is not easy going. We are presented with clues to her predicament along the way, come to care for this yearning woman, and feel the frustrations of her therapist as she sets up roadblocks to their shared inquiry. As the tale unfolds, and Thelma’s therapy proceeds, we are witness to a dramatic, utterly surprising moment worthy of a good mystery story, and a denouement rich in ambiguity. Yalom is left to scratch his head, pondering whether his effort to “dis-illusion” his patient had in fact helped or hurt her. Yet not once throughout the telling does this feel like an academic exercise, as the story (like others in this book) is firmly grounded in such carefully observed details. We are never allowed to forget that we are with a flesh-and-blood person.

Beyond what this subtly rendered story reveals of Thelma, it inevitably stresses the nature of Yalom’s involvement with his patients. These are, after all, stories of individuals in a specific context--the psychotherapeutic relationship. We see Yalom, in this and other stories, as passionately caring, and actively (sometimes aggressively so) involved with his patients. “Since therapists, no less than patients, must face these givens of existence, the professional posture of disinterested objectivity, so necessary to scientific method, is inappropriate. . . . We are all of us in this together.” Yalom does not shrink from revealing his feelings, either to the reader, nor at times to his patients. He can be disarmingly candid at these moments.

In fact, it is the therapist’s struggles with counter-transference--often defined as irrational feelings of the therapist for the patient--that is another central theme of this collection. After all, Yalom asserts, it is in the area of counter-transference that the therapist can constantly seek, though never attain, perfection. And he is able to discuss this, not as a dry abstraction, but in the most concrete and recognizable manner. Here he is at the outset of the poignantly affecting tale, “Fat Lady”: “The day Betty entered my office, the instant I saw her steering her ponderous 250-pound, five-foot, two-inch frame toward my trim, high-tech office chair, I knew that a great trial of counter-transference was in store for me.” What unfolds is not just a tale of a “fat lady,” but of her therapist’s pained effort to examine the sources of his own obstacles to empathy.

There are, however, moments when Yalom’s candor appears somewhat forced, even unconvincing. That may be inevitable in a book about psychotherapy by a still-practicing therapist. Beyond that, not all of these stories are fully successful. Some lack the grace and fluidity of good storytelling, and a couple feel rushed, and end rather abruptly. In these, admittedly few, less compelling tales, Yalom emerges a bit the pedantic teacher rather than the evocative storyteller he can be.

Nonetheless, most of the stories in this collection paint memorable portraits of individuals seeking a way out of their pain, and in the process finding themselves on one of many roads toward a private and possibly redemptive truth. Yalom is a gifted storyteller, and from the sound of these tales, a no-less-gifted psychotherapist. He restores a sense of awe and mystery to an endeavor that all too often gets mired in the muck of jargon and categorization.

In addition to bringing the reader up close to his patients, and to a process often (necessarily) cloaked in secrecy, he gives the reader an un-airbrushed picture of the therapist, warts and all. And throughout this book, he raises thorny questions about the nature of this life, and of the various assumptions that guide and hinder practitioners of the art of psychotherapy on their precarious and uncertain way.