The couch is an iconic symbol of psychotherapy. Look at any portrayal of a therapy session in popular culture, and you’re likely to find this recognizable piece of furniture in the room. Clients are depicted as lying on their backs and looking off in the distance, while their therapist sits behind them, listening attentively and taking notes.
But those of us who are familiar with psychotherapy know that in most cases, the process looks nothing like this. The client instead sits upright in a chair, directly facing the therapist. And our intuition is correct: the couch technique has become less common these days, with some therapy rooms doing away with the couch altogether.
Where did the therapy couch come from? Who still uses it, and why? In this article, we’ll explore the rise and fall of the therapy couch, and learn about some cases in which it can still be helpful.
Origins of the Couch
It was as a young trainee that Sigmund Freud, the originator of psychotherapy, first observed patients lying back on a couch. He had been studying hypnosis, a controversial treatment for mental disorders which involved the patient entering a relaxed state while the doctor made suggestions to them. When it came time to develop his own method, called psychoanalysis, Freud differed greatly from hypnosis. But he did keep one thing the same: the use of the couch.
Why did Freud carry over the couch technique from hypnosis to psychoanalysis? In his writings, he cites both a ‘personal’ and a ‘professional’ reason. As far as his personal reason, he tells us:
“I cannot put up with being stared at by other people for eight hours a day (or more).” (Freud, S., Strachey, J. (1976).The Complete Works of Freud. W.W. Norton & Company, pg. 2487)
We might sympathize with Freud, who wanted to spare himself the fatigue of being scrutinized by his clients. But being absent from their gaze also offered him another advantage, this one related to his technique:
“Since, while I am listening to the patient, I, too, give myself over to the current of my unconscious thoughts, I do not wish my expressions of face to give the patient material for interpretations or to influence him in what he tells me.” (Freud, S., Strachey, J. (1976).The Complete Works of Freud. W.W. Norton & Company, pg. 2487)
Freud tells us that he didn’t want his own reactions towards the client to influence them in any way. Why did he insist on this? His method of psychoanalysis was based on interpretation and insight: the therapist’s job was to listen to the client’s story and offer them interpretations about their unconscious processes. In turn, the insight that the client gained was expected to heal them of their symptoms.
In performing this operation, Freud wanted to observe the client with as few obstacles as possible. As a trained scientist, he considered the therapist’s influence on the client to be an unwanted ‘confounding variable’: the couch eliminated this variable. Thus, by sitting away from the client’s view, he could focus all of his attention on the client’s story, and the unconscious material contained within it.
The Decline of the Therapy Couch
Freud’s method of psychoanalysis was the first modern technique of psychotherapy, but it wouldn’t be the last. In the decades following his technique, the focus of psychotherapeutic theories began to shift from interpretation and insight towards the relationship between the therapist and client. Later research would support this move: we now know that the therapeutic relationship is the single most effective factor in predicting positive outcomes in therapy.
As psychotherapeutic methods began deviating from the strict psychoanalytic model, the use of the couch began to decline. The couch technique is an inherently distancing one: it doesn’t allow the therapist and client to connect with each other. The therapist cannot detect the subtle nonverbal forms of the client’s communication, and perhaps even more importantly, the client cannot gauge the therapist’s response to them.
It shouldn’t surprise us, then, that with the new interpersonally-oriented focus of psychotherapy, therapists began favoring the face-to-face setup.
Today, it is mostly psychoanalysts who use the couch. However, their use of the couch still conforms to the interpersonal focus. They consult with the client about its use, use it collaboratively, and are mindful of any changes in their relationship that result.
Benefits and Disadvantages
If the couch was used in the original method of psychoanalysis, are we losing something by getting rid of it? Or do the upsides of the face-to-face setup outweigh any potential losses?
Proponents of the couch technique offer the following benefits:
- In assuming a reclined posture, the client becomes more vulnerable, and is more likely to offer raw material that is worth being worked-through in therapy
- By removing the therapist from view, the client is less likely to censor themself, leading to improved production of free-associative material
- Removing the therapist from view also makes the client less likely to be distracted, allowing them to be more attuned to their inner mental processes and bodily sensations
Conversely, opponents of the couch technique point out the following disadvantages:
- The reclined posture is removed from any normal human interaction, and may be experienced by the client as alienating and uncomfortable
- The couch technique deprives both therapist and client of important nonverbal communications which can help to understand the client
- The therapist may use the couch defensively, to prevent themself from a healthy amount of scrutiny or feedback from the client
Besides these anecdotal accounts, does the research tell us anything about the utility of the couch technique? Unfortunately, the literature is mixed. One study showed that the reclined posture did improve free association scores; another study found no such association. And no studies have definitely linked the couch technique to improved therapeutic outcomes.
In light of the arguments on both sides, and of the ambiguous nature of the research, where are we left on the topic of the couch technique? The answer — like it is for so many other topics in psychotherapy — is: it depends. Most therapists agree that the couch is best used on a case-by-case basis. Every client should be assessed individually as to whether they will be helped or hindered by the couch technique.
Examples of clients who may benefit from the couch include:
- Overcontrolled clients, who may benefit from the relaxing effects of the couch
- Clients who are overly invested in the therapist’s responses
Examples of clients who may fare best in a face-to-face setup include:
- Clients who seek supportive therapy, which is best accomplished when they can see the therapist’s nonverbal forms of support
- Clients whose anxieties may be exacerbated by the vulnerable position of reclining, or of the distance given by the couch
It’s up to the individual therapist to recognize when the couch technique may lead to a more meaningful and enriching therapeutic experience.
Conclusion
The therapy couch is as old as therapy itself. Freud’s use of the couch reflected his view that the therapist should be a neutral observer to the client’s mental processes, offering them interpretations which would lead to helpful insights. As psychotherapy became more relational, the couch was replaced by the familiar face-to-face setup. Today the couch is used only rarely, and typically during a specialized form of therapy called psychoanalysis.
Given its history, the therapy couch teaches us something important about therapy: techniques are always changing to better suit clients. So if you have a specific method you’d like to try, feel free to discuss it with your therapist. And if it’s the couch you’re curious about, don’t be surprised if they have to take a trip to Ikea first.
