Get Off the Couch!
A Therapist’s Argument Against Using “the Couch” in Psychoanalytic Psychotherapy
Sigmund Freud. There. What comes to mind? A cigar, no doubt. Perhaps a beard. A Viennese accent? A couch?
Ah, the analytic couch. A charmless, armless chaise lounge with a slight incline at its head. This is the patient’s position. The therapist sits upright, often behind and out of sight of the patient, listening, taking notes. Maybe taking a nap. Who knows?
A century has passed since Freud practiced, hypothesized, and wrote the oeuvre that continues to influence psychoanalysis and therapy in general today. In that time, many of his then-novel conjectures have been expanded, enhanced, transformed. Others (looking at you, penis-envy) are understood to be relics of the time in which he wrote, and either mostly abandoned or morphed into ideas that suit the time in which we live.
Psychoanalytic lore posits that Freud began using the couch because he couldn’t bear to sit face-to-face with his patients all day long. He then developed a treatment theory around the use of the couch: Patients are more likely both to freely associate and to project their feelings onto the therapist when free from the relentless gaze of said therapist. Having discussions with and having visited several offices of my colleagues, I can attest that many modern-day analysts continue to subscribe to Freud’s theory (and also, perhaps, cannot bear to sit face-to-face with their patients all day long). The couch is still very much present.
But should it be? I’ll admit to my ignorance on two points. I don’t know if the ability to free associate continues to be a primary goal for analysts, nor do I know of any evidence — empirical or otherwise — that the couch encourages free association in someone who struggles with playfulness and spontaneity. I can, however, attest to the fact that my clients have no inhibitions projecting their fears, feelings, and assumptions on me even though I can look them straight in the eye. I mean, projection is such a common defense mechanism in and out of the therapist’s office, you don’t really need to trick it into emerging.
My real beef with the classic use of the couch, however, comes from both what we know about attunement along with what classical analysis has always given a short shrift: Non-verbal cues. Both words and silence have reigned as analysis’ primary modes of communication. However, in observations and studies from analytic thinkers such as Donald Winnicott, Daniel Stern, Allan Schore, Beatrice Beebe and many more, we know the importance of tone of voice, gaze, facial expression, and body movement and posture when building attachment between caregiver and infant. These basic but vital cues help to inform the strength and type of connection in all relationships.
The use of the couch essentially disembodies both patient and therapist. During the pandemic, I mostly saw clients on video, but for several clients video was not possible so we “met” on the phone. Many analysts who saw their clients on the couch chose to use phone over video to better “reproduce the couch experience.”
Whelp, okay. While I submit that phone sessions are better than no sessions, I felt a tremendous loss, and needless confusion, when working with clients on the phone. I could not always tell when someone was crying. I most certainly could not tell if a client’s eyes were tearing up. I missed their body posture during silences (and, wait, is that a silence, or did we get cut off?), and if their eyes were open or closed or where they were directing their gaze. I could not see their fists clenched, or their fingers drumming. I could not see if they were sitting upright, lying down, shifting from one posture to another. Were they shaking? Were they stifling a yawn? Were they smiling or frowning or curling their lip in disgust?
And what of the client’s experience of me? They missed my smile, my raised brows, the concern in my frown, the empathetic tears in my eyes, the nod or shake of my head. I couldn’t lean in to strengthen an intense moment, or lean back to lighten it.
So much information lost! We are reduced to words alone which can be wholly inadequate, and which may obscure the meanings and emotions of communication. Often words and gestures clash, and that is useful information. You tell me you’re not embarrassed, but you won’t meet my eye. You tell me you’re not anxious, but your foot is tapping some crazy jazz rhythm. You play down your excitement, but your smile can’t be restrained.
Some analysts might argue that the whole point of therapy is to put words to feelings and experiences that have previously been unnamed and unspoken. I believe this is one potential goal of therapy. But the journey to get to that goal is often a difficult one, and why not utilize all the tools available on that journey? Often the body speaks long before the mind catches up, so why cut oneself off from listening to the whole of a person? Why continue to use a couch, to hide the client, to hide from the client?
“Because that’s how it’s always been done” is a weak argument.
Some contemporary, relational-based analytic training programs are moving away from using the couch. I do wonder at this point whether the continued use of the couch in some practices is truly based on what the therapist thinks is better for the patient, or if it’s really — as it was with Freud — better for the therapist.