People Don’t Still Lie on a Couch, Do They?

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by Harvey Schwartz, MD

"The couch" has become the iconic symbol of psychoanalysis in cartoons, television, and movies. However, not all therapists—or even all psychoanalysts—use the couch. When you first consult a therapist, it is unlikely that they will suggest the couch right away. It is an approach that is appropriate for some patients, as well as generally something that one evolves into. While some mental health professionals' consulting rooms include a couch, psychoanalysts are extensively trained to use it as an accompaniment to psychoanalytic therapy.

Why Use the Couch?

More than a century after its use was introduced by Sigmund Freud, the couch still provokes both curiosity and ridicule. Its ability to continue to be evocative is testimony to the imaginings it stimulates.

Freud began utilizing the couch in the early 1900s as an evolution from the authoritative hypnotic method to the more mutual free-associative method. Freud learned—as many subsequent practitioners have—that encounters between the patient and analyst are deepened when they are both freed from the constraints of looking at each other. Both have the opportunity to let their minds run free in relation to each other. The unconscious communication that can result fosters a more profound intimacy and deeper self-discovery.

When patients use the couch they often comment, "It's so freeing to be able to speak my mind without having to worry about your reactions.” On the couch, patients are freed from the subliminal cuing we often rely on to guide our thoughts in face-to-face engagements. We often orient ourselves to the responses we elicit in others. The couch at its essence, then, is a vehicle for personal freedom—freedom from the usual social constraints that inhibit our awareness of ourselves; from the self-consciousness that alienates us from our imaginativeness; and freedom from social superficiality that can inhibit a deeper honesty.

But Does It Work?

A patient began psychotherapy because she noticed that she recently became self-critical as well as disparaging toward her husband, whom she loves deeply. She sought treatment to figure out why. After several sessions, she discovered that her critical attitude toward her husband is the same attitude she has toward herself. She remarked, "Everything I do, I criticize myself for being inadequate." She came to recognize that this chronic sense of critical self-evaluation was related to her upbringing. In her imagination, her mother was constantly critical of her. Later, she recognized that while her mother was in fact harsh at times, her internal picture of her mother was darker than she actually was. She saw that the mother in her imagination whom she always feared was different from her actual mother.

She took to psychotherapy right away and began to feel freer and less self-critical. She related warmly and felt appreciative of my insights. After a while, though, she became uncomfortable and was increasingly silent. One day, she looked at the couch and commented, “People don’t really lie on that anymore, do they?”

I noted her recent awkwardness and wondered along with her about her curiosity about the couch. She had read about it but was embarrassed to admit her interest in trying it. But she was curious about how it worked and how it may be different from face-to-face treatment. I asked her if she was aware of any thoughts that might be easier to speak about if she weren’t looking at me.

In face-to-face treatment, this patient felt awkward about her thoughts. Even though she had appreciated my non-judgmental stance, she was ashamed to speak directly about more personal feelings. She felt I would judge her, as she judges her husband and herself. As it turned out, there were areas of her life she purposely kept secret, and these were the things about which she felt most troubled and deeply ashamed. The couch helped her feel freer so that she could discover the sources of her shame.

“I can say all kinds of things now that I wouldn't be comfortable saying to your face," she said, adding, "For a while now I’ve wanted to tell you that I don’t like your ties, but I never dared to say it to your face."

Curious About The Couch?

Here are some considerations:

• The couch is used when the patient feels ready for it; there is no pressure.
• There isn’t a "right" way to use the couch. It’s a different experience for each patient.
• The couch can allow for levels of honesty that can refresh a patient's life.
• The couch can facilitate self-acceptance and reduce inhibitions.
• The couch can be a place of freedom to discover deeper aspects of one's pains and passions.

If patients or their therapists find that a patient is holding back honest thoughts, if they feel stuck, or if they are seeking to unlock unconscious motivations, perhaps lying back on the couch is just what is needed.

Harvey Schwartz, MD is a clinical professor of psychiatry at Sidney Kimmel Medical School, Philadelphia; Training and Supervising Analyst at the Philadelphia Center for Psychoanalysis and the Institute for Psychoanalytic Education; and is affiliated with the NYU School of Medicine.