What's Up with Lying Down?
Why Psychoanalysts Use a Couch

by Carol Campbell, MFT

The patient lying on the analytic couch is the subject of many funny cartoons, popular movies, and now television dramas. And yet relatively few therapists are psychoanalysts who use a couch to carry out their work. What is it, you may ask, that causes some therapists to ask their patients to lie down for their therapy?

Lying on a couch is not necessarily part of psychoanalytic therapy. Practicing from a psychoanalytic theoretical framework can happen when the patient is sitting in a chair across from the therapist, when the patient is part of a couple seeking therapy together, when the patients are in a group therapy setting, when there is a hospital setting, when the therapist is working in a school or clinic setting — basically in any therapy. Psychoanalytic thinking is a way of organizing the information in a way that is respectful of the patient's history, and that is looking to figure out what is unconscious yet powerful for the patient in a problematic way.

The therapist's couch is just a special tool that some psychoanalysts use to facilitate that process. I find that most of my patients who are serious about committing to therapy in order to really bring about changes to their lives tend to progress faster and with greater comfort when they lie on the couch. I happen to prefer using a plain old, ordinary leather couch with some pillows. Others use a traditional analytic couch with the built-in reclining part for the head and shoulders. (Styles of analytic couches are probably revealing of the analyst's personality and taste, but that is another subject.)

Everybody who uses the couch gets there in his or her own way. Some patients notice the couch and ask if they can use it. Sometimes a patient will start out in a regular chair, but slip farther and farther down in its seat, to the point that I suggest he might be more comfortable lying down. Many times I will raise the topic when I think I have a solid connection with the patient, and that the patient will not be overwhelmed emotionally by lying down. Sometimes a patient will have a dream that suggests she wants to be on the couch.

Lying down is associated with some emotionally charged ideas: sleeping, being vulnerable to harm, sex, dreaming, being in a crib as a baby, resting comfortably, etc., etc. So lying down in a therapy session is a sure-fire way to access some provocative thoughts and feelings, which can be clues for the therapist about how to be helpful to the patient.

When you see a cartoon about psychoanalysis, notice where the cartoonist places the chair of the therapist. If the therapist's chair is behind the patient and out of his or her sight, then you can bet that the cartoonist knows something about analysis. If it is next to the patient or facing the patient, the cartoonist is probably faking familiarity with the practice. The standard practice is for the therapist's chair to be placed very close to the couch, but behind the patient and essentially out of sight.

In this manner, the analyst is able to be in close physical proximity to the patient, a fact that conveys constantly to the patient the watchfulness and attentiveness of the analyst. Being out of sight accomplishes two important goals: (1) the analyst is freed from concern about her own body language, and has essentially total privacy in which to be trying to feel whatever the patient is feeling and to focus on accessing her own unconscious responses to the clinical material; and (2) the patient finds it much easier to focus on his own mind, and to engage in fantasies that have nothing to do with normal social engagement with another person.

Lying on the couch is about eliciting unscripted, spontaneous thoughts and feelings in the patient, while simultaneously conveying a sense of being deeply cared for and understood by the analyst. The process is often compared to a mother rocking her baby in her arms. The patient/baby does not need to meet any expectations, please anybody, accomplish anything — but just be there being cared for. That experience is profoundly important for the successful development of a human being's emotional self. If things did not go well in that regard the first time around, psychoanalysis can provide an excellent repair job. I highly recommend it!

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Carol L. Campbell, MFT, is a licensed marriage and family therapist providing psychotherapy and psychoanalysis for individual adults and couples in Palo Alto, California. She has degrees from Brown University and Santa Clara University and has been licensed since 1991. Carol is a graduate of the Palo Alto Psychoanalytic Psychotherapy Training Program sponsored at Stanford by the San Francisco Center for Psychoanalysis and was a candidate at the Psychoanalytic Institute of Northern California in San Francisco from 2010-2011. She is also a clinical member of the California Association of Marriage and Family Therapists and the Northern California Society for Psychoanalytic Psychology.