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Summary:

This is the story of Betty, a 250-pound, 5-foot-2-inch woman who comes to the psychiatrist-narrator's office to be treated for her eating disorder. What makes the story more than the sad tale of a depressed, obese woman is the immediate disclosure of the narrator that he is "repelled" and "disgusted" by fat women, that his "contempt surpasses all cultural norms."

Nevertheless, he decides to treat Betty, who successfully manages to shed huge amounts of weight and come to terms with many of the problems leading to her obesity. The narrator, too, confronts his own excessive biases so that readers are left with a sense that Betty "helped" him too.

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Dr. Ernest Lash, single and around 40, discovers his enthusiasm and love for psychoanalysis, the talking therapy, after several years of practice as a psychopharmacologist. As the novel opens, we meet a smart, somewhat smug and self-absorbed Dr. Lash who practices from his office located in the privileged community surrounding Sacramento Street in San Francisco. He has an active psychoanalytic practice, ambition for respect and notice by the seniors of his professional community, and some aspiration to greater success as a theoretician and writer on the subject of psychoanalysis. Central to his character is a love for his work, where it appears that pride in technique and outcome shadows genuine concern for his patients and their unhappiness.

Early in the novel, a male patient, Justin, who has been working with Ernest for several years, announces that he is leaving his wife, Carol, for another woman. Ernest is pleased since he views the marriage between Justin and Carol as unhealthy, while a bit dismayed that Justin fails to acknowledge Ernest's contribution in helping Justin develop the confidence to take this step. Justin ends his relationship with Ernest Lash--feeling that he no longer needs his help--as the beginning of the novel takes an intriguing direction.

Justin's now abandoned wife, Carol, in a state of betrayal and desire for vengeance--she has a hateful attitude toward all psychiatrists after her psychotherapist of many years ago had an affair with her--decides to enter therapy with Dr. Ernest Lash in the hope of seducing him. She disguises herself with a name change and enough distortion of her past and present so that Dr. Lash will not be able to connect her to Justin. She wishes to expose him as a charlatan, and destroy his career.

Carol is an attorney, and smart. Dr. Ernest Lash is lonely and drawn to Carol. The therapy sessions and the progression of their relationship are central to Yalom's exploration of the intersubjective experience, where strangers struggle with the ambiguity of their own motives and intentions in the intimate world of psychoanalysis. Who is giving, who is receiving? Who is being helped, and who is helping?

Yalom weaves this central element of the plot with many other relationships. Dr. Marshal Streider is a senior psychoanalyst with ambitions for national recognition and a preoccupation with money. He is Dr. Ernest Lash's supervisor. He takes great pride in the fact that he treats many wealthy patients, and is engaged in his own boundary dilemmas when he invests, using insider information from one of his patients.

Dr. Seymour Trotter is a senior psychoanalyst who is condemned and removed from psychoanalytic practice after entering a sexual relationship with one of his patients. We learn that Seymour Trotter was once president of the American Psychiatric Association, and a mentor to Marshal Streider. His maxim, "My technique is to abandon all technique" (p. 7), both haunts and guides Ernest Lash throughout the novel as Ernest grapples with his own passions and temptations, while striving in his goal to achieve humane and healing therapy for his patients.

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The story begins in 1882, when Friedrich Nietzsche's beautiful and mysterious former lover convinces the famous Viennese physician and mentor to Sigmund Freud, Joseph Breuer, to cure Nietzsche of his "despair" so that the world will not be deprived of the "most important philosopher of the next 100 years." Breuer is known throughout Europe for his use of hypnosis and the "talking treatment" that have been successful in the treatment of hysteria.

Since Nietzsche is skeptical of what Breuer can do for him, Breuer offers the challenge that they might help each other. Through subterfuge, Breuer convinces Nietzsche to remain for 1 month in the Lauzon Clinic. Their bargain: Breuer agrees to treat Nietzsche for his chronic migraine headaches, if Nietzsche, the great philosopher, will listen to and cure Breuer of his own despair. What follows is a brilliant tour de force in which the two men engage in daily discussion, bantering, and intrigue, much like a chess game, jockeying for position, as both men are transformed in unpredictable and astonishing ways.

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