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What's the Couch Got to Do With It?

The lowdown on lying down on the couch in psychoanalysis.

My recent posts on “What Is Psychoanalysis?” have generated some very thoughtful comments and questions. One reader wanted to know more about the use of the couch in psychoanalysis. She commented, "You wrote that the couch opens people up as opposed to their sitting in a chair facing you. Is there any research to support this, or is this based just on a feeling?”

As far as I know, there are no research studies using the experimental method that explore whether or not the use of the couch facilitates the process or outcome of psychoanalysis, although many analysts and patients will tell you from their personal experience that they believe it does. If you’re looking for a thorough discussion of the topic, Ahron Friedberg and Louis Linn wrote a very interesting paper, “The Couch as Icon” (Psychoanalytic Review, February 2012), in which they reviewed over 400 articles from the psychoanalytic literature (clinical and theoretical) about the use of the couch. New York psychoanalyst and photographer, Mark Gerald, explored the use of the couch through a photographic study and gave a very insightful interview, “The Evolution of the Psychoanalyst’s Office” that I highly recommend.

It is curious to me that people are so surprised when they hear that psychoanalysts still use the couch with their patients. After all, when you picture the scene of a psychoanalytic session in your mind, don’t you envision the patient lying down on the couch with the therapist sitting behind, jotting down notes on a pad? This picture is the subject of many a New Yorker cartoon and is, in fact (although perhaps without the notepad), the way most psychoanalysts have practiced since Freud set up the whole thing.

But when people ask me about my actual psychoanalytic practice—or even about my own analysis as a patient—they often ask incredulously, “People still lie down on the couch? Really? You’ve got to be kidding!” Even though they know the stereotype, they don’t believe it could possibly be so. Perhaps they think such an arrangement must have been left in the past, having outgrown its usefulness or having never been very useful at all.

The idea that this physical arrangement could be useful is difficult to understand at first. It does, however, seem to facilitate the most important process of psychoanalysis: free association. Free association is the procedure in which the patient says everything that comes to mind—without censoring, without filtering, and without judgment. It is essential to psychoanalysis because it is how the unconscious reveals itself. When we recline, we drift into that more dream-like state in which we recall forgotten feelings and memories, where we gain access to deeper sensations, fantasies, anxieties, and longings. Freud acknowledged that this recumbent position is reminiscent of the hypnotic method from which psychoanalysis first evolved.

The use of the couch is believed to be useful for both patient and analyst. It helps reduce the natural tendency toward reassurance that is a built-in expectation of social discourse. When we interact face-to-face, we are held together psychically by eye contact and facial expressions. There is an implicit pressure to be polite, to smile, to nod our heads in understanding and approval. While we need this kind of supportive contact in most of our relationships, the psychoanalytic situation is different. There we want to get beneath the surface and beyond the ordinary concerns of the day. We want to talk about more than what we would say at the dinner table. Otherwise, how can we really get to the bottom of things?

The physical arrangement of analysis also can be helpful for the analyst. Freud admitted that he first came up with the idea because he could not put up with being stared at by other people for eight hours a day—a very practical consideration! But there are deeper reasons, too. The use of the couch changes the pace of the interaction. There is less pressure to keep up with the ordinary to-and-fro of a more social, conversational interaction. In addition to making room for the patient to say more, there is room for the analyst to think more—and analysts need a lot of freedom and space to think in order to do their job well. They need to listen deeply, reflect, and make connections in order to begin to understand what is going on in the patient’s unconscious inner world. So the use of the couch helps both patient and analyst to unwind, to let thoughts wander, to gain access to the unconscious mind where deeper contact and understanding can be found.

For my part, I much prefer to work with my patients when they are lying down, as I can listen and think at a deeper level. As a patient in my own analysis, I also have found the experience of lying down to be conducive to thinking and saying aloud what I might not think or say if I were looking into my analyst’s eyes. I recollect dreams I thought I had forgotten, details that had eluded me when I first walked in the door, and fleeting thoughts and feelings that I previously had considered unimportant. While lying on the couch, I have the courage to say what might otherwise feel too embarrassing, too hostile, too vulnerable, or even too crazy to say.

As a final note, I think it is important to keep in mind that the use of the couch is potentially helpful but not essential to a successful analysis. The couch is a servant, not a master. It is a means to a greater end. What is most important is to create a safe space in which the patient feels free to tell the analyst more and more. If that atmosphere can be created in a face-to-face arrangement, then I say "so be it." But if the patient and analyst can bear the added vulnerability of using the couch, an unusual and precious freedom of expression may be found.

Copyright 2014 Jennifer Kunst, Ph.D.