Even today, when people think of seeing a psychoanalyst or psychiatrist, they may have a mental image of a patient lying down on a couch with a thoughtful therapist sitting beside or behind them with a notebook in hand. However, thoughts on the use of the couch in psychotherapy or psychoanalysis differed even in the early days. 

Freud was a famous exponent of patients lying down and photos of his sumptuous-looking couch covered in a multi-coloured blanket and soft cushions, with Freud’s chair positioned at the head end enabling him to listen with his left ear (he had hearing loss in his right), have been reproduced countless times. Reportedly, Freud’s initial reasoning for the use of the couch was that he wanted to avoid being looked at for many hours a day by his patients! He subsequently realised that lying down on the couch enabled his patients to free associate, allowing them to explore whatever thoughts came into their minds without censorship, and liberating them from conventional restraints. He also became aware of the freedom it provided to the therapist, allowing space to think analytically rather than being constrained by conscious or unconscious expectations of social interactions from possibly both patient and therapist.

In contrast, Carl Jung, once a supporter, friend and colleague of Freud, in developing his own analytic ideas and theories, gave up the use of the couch, preferring instead to work with people sitting up and facing him. He felt that the therapeutic relationship of the two people in the room i.e. therapist and analysand, was of great importance and that this relationship was facilitated by working face to face. Obviously much theoretical thinking has evolved since Freud and Jung’s days and many Jungian practitioners work with patients on the couch as well as sitting upright.

In my private practice, I have worked with people who have been both been lying down and sitting up. My experience has been that when patients have decided to use the couch, it has usually had a significant impact on the therapy. There has been the opportunity for us both to bear and use silences for reflection, to allow feelings and thoughts to emerge and be explored without concern for usual social discourse. In short it has allowed more freedom and movement within the room, within the patients’ psyche and the therapeutic alliance.

However, for some, the couch may be quite frightening or daunting. A great degree of trust in the therapist is needed and even then, the feelings evoked when lying down can be quite overwhelming and unbearable. Victims of sexual abuse, as just one example, may possibly find feelings of vulnerability and anxiety too great and that lying down is a re-enactment of the original abuse. There may also be other parallels or links with the past that, whilst still needing to be explored and worked through, may be too distressing to think about. A patient of mine who had been using the couch for a significant period (which I considered to have been hugely beneficial to the work), divulged that their feelings when lying down, were unbearable. These feelings linked with very early childhood trauma. That patient now sits up, at least for the time being, and the possibility of lying down cannot currently be thought about. Although this example may lead one to conclude that the use of the couch caused further suffering to the patient, it could also be argued that the patients’ very use of the couch elicited some previously inaccessible feelings to emerge and be acknowledged and subsequently worked through.

In conclusion, I consider that a patients’ choice to use the couch or a therapists’ choice to provide a couch is, very individual but careful consideration is needed. Thought needs to be given to the frequency of the therapy. My own view is that lying down might not always be suitable for patients in once-weekly therapy which may not be containing enough for the emerging material. Lying down can enhance the work and allow other unattainable thoughts and feelings to manifest but as the above example shows these can be unbearable to some patients.

For some people, it may be beneficial to lie down or sit at different stages of their therapy but it is important that the choice is theirs, until perhaps the ending when it can be important for the patient to be upright and grounded and be able to face their therapist to say goodbye.