Friday, May 22, 2009

Working with the Couch

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist,
Dublin, Ireland.


As a piece of furniture the couch probably attracts more interest than anything else in my consulting room. Of course when I say couch I should more accurately describe it as a chaise longue, which is defined as an upholstered couch in the shape of a chair that is long enough to support a person’s legs. But calling it a couch works just as well.
I suppose it attracts interest because over the past 150 years, since Freud first gave us psychoanalysis as the original form of psychotherapy, the couch has become very much more than a piece of furniture. It has come to symbolize a great many things, possibly even psychotherapy itself.
In the process it has had its detractors from other schools of therapy who have seen in it an opportunity to criticize, sometimes with merit, sometimes not, custom and practice and, with much less success, the underlying theory.
You could say it has almost become a touchstone for inter-disciplinary strife, which is a great pity because we are all trying to achieve the same objective and at the end of the day it really is only a couch.
Freud began using it because his first forays into probing the unconscious mind of a Victorian-era clientele was through hypnosis. And when you hypnostise someone you want them to be in a comfortable position so they don’t fall over. When he left hypnosis behind and discovered the ‘talking cure’, in doing so founding the beginnings of all psychotherapies, he kept the couch.
Following his death, and even during his lifetime, splits and differences led eventually to what we have today in the form of three broad streams of psychotherapy. There is psychoanalysis and psychoanalytic psychotherapy which continues to use the couch and which, despite the claims from other branches of psychotherapy, is alive and well throughout the world.
Then there is the humanistic stream and the behaviourist stream, the former giving privilege to the notion of the conscious mind and the intrinsic wholeness of the person, the latter giving privilege to actively re-learning and retraining the person to more effective modes of both physical and mental behaviours. These two streams don’t have too much in common except they do not use the couch.
So what is it about the couch? The idea behind it, officially, is that Freud wanted to increase the ability of the client to allow ideas and thoughts, without censorship or editing, enter their mind. This happens because the client, by lying in a comfortable position facing away from the therapist, is not being impeded by the facial gaze of the therapist or the surreptitious body language that might inhibit this process. To this day, this objective has and continues to be fully met by the use of the couch.
Clients who work on the couch will tell you that it allows them the freedom to both relax and focus on their thoughts without have to attend to every little bodily cue that emanates from the therapist. It also, and more importantly, frees up the thinking process so that ideas come much more easily that can then be brought into the session.
That’s not to say that those of us who work with the couch are impervious to the cultural stereotyping that goes with it. Psychoanalysis has been around for a long time and it will continue to be. It also, by its very nature, deals with fundamental issues in people’s lives. The cultural stereotype of being ‘on the couch’, when it pokes fun at our doings, is a useful puncturing of the balloon and ensures we never get to complacent or smug or self-righteous. And that’s a good thing. It means we who practise have to be constantly reviewing its effectiveness and clarifying for ourselves the rationale for using the couch.
Psychoanalysis has become a classic target of cartoonists. Freud said that cartoons represent "a rebellion against [...] authority, a liberation from the oppression it imposes". So it was perhaps only fitting that the cartoon should be the medium for the longest-running and most iconic piece of send-up in the history of psychotherapy.
The ‘On the Couch’ cartoon that appears in The New Yorker magazine documents nearly 80 years of this send-up or rebellion against authority. The magazine published its first “psychoanalytic” cartoon in 1927 and since then its cartoonists have continually renewed the topic within the context of their own times.
So does everyone end up on the couch? No is the answer to that. Some clients sit in a chair facing me and do so for the duration of their therapy. The criterion for who uses and who does not use the couch is a detailed one. People in a high state of anxiety or in deep depression are not suited to it until their symptoms have reduced; nor are those who come with a rejection or a refusal to accept the notion of therapy and, believe it or not, some people do. And equally people with relationship issues who come to discuss the issues at hand as to why they are in or have endured in a relationship that is unfulfilling are not necessarily candidates for the couch. Often some people simply need to talk. As Freud is reputed to have said: sometimes a cigar is just a cigar.
But for the vast majority who come with a question, albeit one that may not yet be formed but which is forming within them, then the couch is the most effective form of therapy. For those who live lives of constant doubt, anguish or repetition and who question why their life is that way and how it can be changed, the effectiveness of the couch and the freedom – because freedom is really what it is – it offers is unparalleled anywhere, in any other form of therapy.
Not only is it a powerful method which allows people access parts of themselves they never thought possible. But to engage in the important business of examining one’s life in the presence of a trained other and without the gaze of that ‘other’ distracting them at every turn is the ultimate respect that can be paid to anyone.

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