Why do some therapists use a couch and some don’t? What’s the purpose of the couch? And how can I choose the best therapist and method of psychotherapy for me?
There are two things I am generally questioned about when it comes to my work. The first is: “Can you read my mind?” The second one arises when people enter my study: “Where’s the couch?” I fear that when I answer, “There isn’t any couch here,” there’s also a third question which they don’t express: “Er… you are a psychologist, aren’t you?” So let’s spend some time talking about this sacred cow of psychology — the couch stuff.
Firstly, many psychologists’ offices have no couch. I know this will surprise many readers, but I can assure you it’s true. Some might think: well, probably couches are only in very good and experienced psychologists’ offices. Not at all. There is no link between experience and couches.
Now those who know something about psychology may say that the real link is between couches and psychoanalysis (you know that psychoanalysis and psychology aren’t the same, don’t you?). But this is not true either, because you can also find psychoanalysts without a couch.
And when I hear this familiar comment I wonder: why on earth do people believe we all have couches?
I have a hypothesis. I probably sound monotonous always turning to Freud, but I do that because Freud’s work had such impact and prominence that we are likely to find its traces in many laymen’s images of psychology. The couch is one of these traces.
By the way, if you want to see Freud’s couch (pictured above) you can go to 20 Maresfield Gardens, London. This is where he lived the last months of his life, after escaping from Vienna at the start of World War II and the Nazi persecution against Jews. He died there “in freedom” in 1939 from jaw cancer. When you enter the elegant cottage, look to your right and there it is — the consulting room with the couch (it’s the original one, brought there from Vienna). As you can see, Freud sat on an armchair behind the patient so that the latter could not see him but Freud himself could see the patient. For the purists’ sake I’ll add that the actual position of the armchair, with the patient at Freud’s left, is not the original one; in the beginning the patient lay on Freud’s right side. Due to his cancer he became deaf in the right ear and started having trouble hearing patients, so he had to change the position of the patient to his left side.
Another likely question is: OK, Freud used the couch, but why? After all, one can just as easily speak about their problems on a common armchair — and Freud was sitting down — so why couldn’t the patient sit? Why on earth should one lie down? Furthermore, why not look at the person you’re talking to? Surely it’s easier, face to face?
Typically, questions have two answers — a theoretical one and a practical one. I also have a third one, which I’ll add at the end.
Firstly, with their back turned to the analyst patients can concentrate better on their thoughts because they are not distracted by the visual contact with the therapist. Also, the prone position helps a patient to regress (i.e., to recall childhood), which is considered important in order to access old, forgotten feelings and sensations, which can help in understanding the present situation.
Secondly, and more practically, Freud said he, personally, didn’t enjoy being looked at by his patients for the entire day. So it was also a very particular thing about Freud’s likes and dislikes — I love this, it shows how people’s actions are sometimes guided by simple reasons as well as by profound ones.
I said that I also have a third reason: it can be easy to forget that Freud didn’t study “Psychoanalysis” at University because, obviously, it didn’t exist yet — in fact he studied Medicine. So he couldn’t know how psychoanalysts work because they didn’t exist yet. As a physician, he did know how doctors work. So when dealing with patients he behaved like a doctor and asked the patient to lie on the examination table. Period.
OK, so couches aren’t compulsory, but where do you find them? Possibly anywhere; not just in psychoanalysts’ consultation rooms because use of the couch doesn’t depend only on theoretical approach. Classical psychoanalysts use them, but there are also many who prefer not to work with couches and prefer to have their patients sit in front of them, in order to interact directly with them. Add to this that some patients may not enjoy lying down — they could dislike it so much that it dramatically interferes with their therapeutic process. That’s why, when I was studying psychoanalysis, my teachers used to be extremely clear on this subject: “Use the couch if you think it’s good for your work and your patients” — more practical than romantic.
An excellent example of a non-couch shrink is in the tv show “In Treatment”, which follows a psychologist’s working week. Dr. Paul Weston meets his patients face to face — in Italy we use the French expression “vis à vis psychotherapy” to describe this approach — as he himself works when he goes to see his senior colleague Gina to seek help for his personal and professional troubles.
So if couches aren’t compulsory then what might you find in a psychologist’s office?
Armchairs and chairs are a possibility; and desks — when I worked for the Italian National Health Service my office was furnished with a desk and some chairs, no armchairs and no couches at all. If you go to a child psychologist you could find a mat and many toys — for many psychologists toys are a powerful way for children to express feelings without any need for words. In the office of Freud’s daughter Anna, a psychoanalyst herself, you’ll find… a loom — she was keen on weaving and so she kept it with her. Go to the upper floor of Freud’s house and see Anna Freud’s consultation room.
And now the last question: which is better, therapy with or without a couch? Answer: both. I mean, there are dozens of different therapies and techniques and schools. Some use the couch and some don’t. If we don’t want to think of psychology like a football fan question, we must agree that there is no ‘Best Ever Psychological School’. So it’s useless asking which is the best technique because each one can be the ‘best choice’ for some patients. Just as an example — at the beginning of this post I said that I have no couch in my study. But when I underwent my own analysis (have you ever heard that analysts must themselves be analyzed?) I lay on the couch, and I thought it was the best for me — had I not liked it, I would simply have chosen another therapist.
So the difficult thing, rather than decide which method is the best for treating patients, is to find which psychologist is the most suitable for which patient. How can one do this? Well, as usual the best route is a simple one: ask. Rather than focus on the many differences between the various schools, which are sometimes of no importance for laymen, I think a patient might want to know more practical things like: What will we be doing during the sessions? How long does a session last? How long does a complete therapy last? Is it possible to determine that in advance? And, yes — will I be sitting in front of the therapist or will I be lying on the couch? All of this and more can be asked. A good psychologist is glad to inform patients about these practical issues because he or she knows that what is good for one person might be bad for someone else, and different situations can make different people feel comfortable or uncomfortable. Couches included.