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Psychoanalytic Inquiry: A
Topical Journal for Mental
Health Professionals
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A reassessment of the couch

in psychoanalysis
a b c
James S. Grotstein M.D.
a
Clinical Professor of Psychiatry , University of
California , Los Angeles
b
Training and Supervising Analyst at the Los
Angeles Psychoanalytic Institute
c
522 Dalehurst Avenue Los Angeles, Los Angeles,
CA, 90024
Published online: 20 Oct 2009.

To cite this article: James S. Grotstein M.D. (1995) A reassessment of the couch
in psychoanalysis, Psychoanalytic Inquiry: A Topical Journal for Mental Health
Professionals, 15:3, 396-405

To link to this article: http://dx.doi.org/10.1080/07351699509534045

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A Reassessment of the Couch
in Psychoanalysis
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J A M E S S. G R O T S T E I N , M.D.

T HE USE OF THE COUCH for the treatment of mental disorders has a

history that long antedates Freud's initial employment of it. The
ancient Greeks apparently practiced an equivalent form of psycho-
analysis that was characterized by the use of the couch; dream analy-
sis; and the employment of rhetoric, dialectic, and catharsis (Entralgo,
1970; Simon, 1978). It is not clear what their rationale was for the use
of the couch. As we now know, Freud's suggestion that the patient use
the couch was largely for personal reasons. He did not want to be
observed while thinking about the patient's free associations, and he
also believed that the patient, by feeling more comfortable lying
down, would be able to tap into deeper layers of preconscious
phantasies.
Freud apparently never realized that he had, in effect, discovered
the right brain hemisphere! When a person lies down and does not
make eye contact with the other person in the discourse, he or she
seems to activate a cerebral hemispheric shift in terms of modes of
data processing from the left to the right in right-handed persons and
vice versa for left-handed persons. Interestingly, researchers in infant
observation also noted that there was a noticeable difference in infant
alertness when the infant was observed sitting up as contrasted with
lying down. This shift in the alertness of consciousness corresponded
to electroencephalographic changes in states of alertness and also to a
hemispheric shift. The shift is from a highly controlled, organized,

Dr. Grotstein is Clinical Professor of Psychiatry at the University of California at Los

Angeles, and Training and Supervising Analyst at the Los Angeles Psychoanalytic Institute.

396
REASSESSMENT OF THE COUCH 397

linear, abstract mode to a looser, more free-flowing, somewhat more

desultory, field-dependent mode. The term field dependent suggests a
state of mind in which the subject is dominated by and organized
around emotions and phantasies and, as a consequence, searches for
those objects in the environment, internally and externally, that
seemingly support or confirm that mental state. This "right-brain"
shift in the lying-down position in analysis would be demonstrated by
the nature of the patient's associations. These would be "free" i.e.,
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optimally disconnected from "left-brain" editing, censorship, and

control and would instead be organized by the unconscious. The use
of the couch dramatizes, exaggerates, and allows the unconscious to
select. One can conclude from this that lying down facilitates a shift
from the real to the imaginative, phantasmal, and illusory worlds.1
While it is well known that the stoic aspects of psychoanalytic
technique issue from Freud's rationale, that the discharge into action
of the instinctual drives should be thwarted to allow for a verbal trans-
formation, one can also hypothesize that another perspective of the
stoic rationale is to facilitate the emergence and enhancement of
the dramatic aspects of one's inner life so that they can become
recognized.
Thus, when psychoanalysis is thought of from the perspective of
dramaturgy, one can see that a "play" is being enacted that, on the one
hand, is improvisational vis-à-vis consciousness but that seems, on the
other hand, to have been already prepared for revelation by the uncon-
scious. Patient and analyst are enabled to participate in this play by
the austerity and discipline of their respective roles and how diligently
each plays the role. The sitting-up, face-to-face position vitiates the
intensity and authenticity of the performance of this "play." Further,
by lying down, the patient is only seemingly speaking to the analyst.
He or she is, on a deeper level, participating in an act of discourse
with himself or herself through the analyst as channel (Lacan's, 1975,
"Other"). That is, his or her unconscious is discoursing with itself
through the analyst, but the impact and recognition of this refraction
through the Other on the ego constitutes the methodology of psycho-
analysis. Consequently, when we lie down, the boundaries between

1
The right hemisphere "speaks" analogically in terms of sense impressions, especially visual.
The mode it employs is generally the visual, which in turn subserves the functions of imag(e)-
ination as well as phantasy and illusion.
398 JAMES S. GROTSTEIN

our conscious and unconscious and between ourselves and the Other
(and others) become more fluid and therefore more revelatory. The
patient on the couch feels more free to retrieve his or her deeper feel-
ing states, to be immersed in them, and to ponder them.
The relation between the use of the couch and the unusual nature of
psychoanalytic discourse evokes yet another rarely addressed point. In
ordinary conversation, as well as in psychotherapy, we engage the
other person or patient one-on-one; that is, we listen and speak
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directly to the other person as a person ("I-thou"). In psychoanalysis,

on the other hand, the analyst, strictly conceived, listens not to the
speaking patient but to the text of associations from the patient's
unconscious, for which the patient's conscious speech (free associa-
tions) is merely the "channel." Likewise, when the analyst interprets,
he or she speaks to the unconscious through the conscious ego, not to
the patient per se. The use of the couch facilitates this unique dialogue
(Grotstein, 1995c).
It is well recognized that the very act of lying down on a couch in
the presence of another person, a professional "stranger," is awkward
and even potentially embarrassing. To say the least, it is felt to be
unreal. Beginning patients frequently fear falling asleep, entering into
states of dissociation, and being abandoned. They feel self-conscious
and naked. The illusory world begins imperceptibly to emerge. One
patient, upon recently changing from the chair to the couch, put it this
way: "This is an awkward and even an eery situation. When I'm lying
down, my image of you seems to change. You become awesome,
intimidating, larger than life. When I get up to leave and am able to
face you, you seem to shrink down to human size."
Another aspect of this hallmark position is worthy of note. Lying
down facilitates the attainment of that brain state known electroen-
cephalographically as theta rhythm, which corresponds to what Bion
(1959) termed reverie—the state that characterizes the receptivity of
a nursing mother and the receptive state of her infant during the
nursing. It corresponds to a trance state of optimal receptivity to
impulses from within and from the external world with a minimum of
defensiveness. In this state of reverie, the mother's alpha function,
which Bion (1992) termed dreamwork alpha in his personal and hith-
erto unpublished diary, is enabled to function optimally. It is impor-
tant to realize that Bion's term dreamwork alpha, which can be
REASSESSMENT OF THE COUCH 399

thought of as daydreaming or, more precisely, the continuation of the

dreaming process in wakefulness, offers a new dimension to psycho-
analysis.
Thus, the analyst, like the mother, receives the patient's associa-
tions in a daydream state and then processes them cognitively. The
same is true of the patient who, like the infant, takes in the results of
mother's "digestion" of his reported experiences also in a state of
reverie (when the resistances to the attainment of this state have been
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uncovered and removed). Consequently, the phenomenon of analytic

insight has a dimension in which the patient experiences his or her
interpreted truth, as revealed by the analyst, not only consciously
(cognitively) but also preconsciously and even unconsciously
emotionally. Perhaps we have overestimated the importance of the
ego in psychoanalysis, especially as it seems to have been privileged
at the expense of the id. What is of relevance here, however, is that if
we employ Bion's conception of the optimal mutuality of dreamwork
alpha, then psychoanalytic treatment not only involves itself with the
unconscious, but may be a more "interunconscious" and "intraun-
conscious" discourse than we have hitherto realized; if so, the
requirement that the patient lie down on the couch has found a new
rationale.
Yet another aspect of the use of the couch involves the matter of the
patient's trust of the analyst as well as its reciprocal—the analyst's
emotional willingness to bear the patient and to allow him or her into
his or her dream life, to continue Bion's idea. This intimate relation-
ship can be understood as analogous to bonding and attachment
(Bowlby, 1958, 1969, 1973, 1980) but also harkens back to Freud's
(1905) conception oicathexis {Besetzung), which is best translated as
"personal investment in" or "belonging to." In another contribution, I
(Grotstein, 1986, 1995a, b) described this under the rubric of the
"dual-track theorem" as the "transference-countertransference neuro-
sis," which is the return of the repressed infantile neuroses of the
patient and analyst both as separate and inseparable phenomena, as
following a "Siamese-twinship" paradigm (Grotstein, 1978, 1980,
1986, 1988, 1995b). The patient's lying down and facing away from
the analyst conjoins with the freedom offered the latter to think his or
her own thoughts without intrusion by the putatively invasively
concerned eyes of the patient to allow each to follow their respec-
400 JAMES S. GROTSTEIN

tively assigned "roles" optimally, but this involves trusting one

another. This act of mutual trust follows from the act of therapeutic
bonding and attachment.
It has been shown paradoxically, nevertheless, that bonding and
attachment in the infant-parent situation is facilitated by the mutual
eye-gaze act. Perhaps analysis, unlike the birth situation, is a unique
event in which the very forfeiture of the gaze option allows for an
opening of the channels into the interior of each participant. Again,
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following Bion (1962) and his admonition to analysts to abandon

(really, suspend) memory, desire, and understanding, the very act of
the exclusion of one's senses facilitates all the more the development
of that gaze within known as intuition.
I return to the paradigmatic image of the Siamese-twinship to which
I alluded earlier and apply it to the phenomenon of bonding and
attachment. The Siamese-twinship is an image that conveys the dual-
track phenomenon, which in turn conveys both a dialectical (closed
system) of entities that are seemingly independent but which are really
constantly conjoined (Bion, 1962) and dialogical (open system). The
therapeutic alliance is an example of the latter, whereas the transfer-
ence-countertransference situation is an example of the former. To
these ideas I add yet another—the background presence of primary
identification (Grotstein, 1978, 1980). This entity has many aspects,
but the one that is apposite for our consideration is that of a "rearing
object"—one who stands behind (or under, as in "understanding") the
patient, who "rears" him or her, and who sends the patient forth on his
or her journey through the analysis and into life. The geographic loca-
tion of the analyst behind the patient allows for the concretization and
actualization of this spatial relationship as a vital metaphor, one in
which the patient can imagine that he or she is sitting on the analyst's
lap (when dominated by the phantasy of the analyst as nurturing) and
as persecuting and "stabbed in the back" (betrayed) when the negative
transference is predominant.
Some patients seem to temporize their analytic posture by sitting on
the couch and looking at the analyst. I have found on occasion that
some patients may seek items to talk about that seem to justify their
sitting up and facing the analyst. One of the basic considerations for
the use of the couch is the therapist's judgment as to whether the
patient is capable of adaptive regression in the service of the ego or
REASSESSMENT OF THE COUCH 401

might descend headlong into a cataclysmic regression, in which case

the use of the couch is generally considered to be contraindicated.
Considerations of this anxiety about regression oftentimes lurk behind
the maneuvers of the patient to sit on the couch or in the chair.
The patient may feel that his or her gazing at the analyst is a pro-
tective measure that will arrest the danger of a deeper regression in the
treatment.
It is interesting to note how often patients who return for brief
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consultations or follow-ups, even after many years absence, will

instantly head for the couch as if it is their childhood room. Appar-
ently, for them the couch had become a ritual.
The concept of the couch as a ritual has yet another dimension—its
being generally considered a formal requirement for the psychoana-
lytic procedure. Frequently, a great deal of pressure is placed on
candidates in training to persuade their patients to use the couch, and
many "tricks" are employed by them and by seasoned analysts as well
to lure their patients to the couch. I myself have opted for a routine
procedure that seems to be successful thus far. My procedure for this,
which I interpose as soon as I have finished the consultation and
obtained the patient's consent to begin analysis, can be generically
stated thus:

Now that we have agreed upon the advisability of your entering

analysis, I wish to introduce you to how it is conducted. One of
the procedures is the use of the couch. Have you any ideas or
feelings about its use? The rationale for its use began with Freud
and his discomfort in being observed while immersed in his
thoughts about the patient. Further, he thought that the patient
would feel more comfortable lying down. He did not recognize
that he had in effect discovered the right hemisphere, an alterna-
tive brain that is switched on as the other switches off when
someone lies down in the presence of another person without
being able to observe them with their eyes. This data-processing
system is sensitive to emotions, phantasies, illusions, and the like
and is less concerned with logic or continuity than the other one.
I think you will be able to see this for yourself. Yet you must
know that it is not required of you if you find it uncomfortable
or disquieting. Yet the very reasons that you might conceivably
402 JAMES S. GROTSTEIN

find it unpleasant would themselves be important for us to

understand.

What seems at times to be at issue in terms of the use of the couch

clusters around considerations that transcend its original, casual, and
even serendipitous origins in convenience. It has become ritualized
rather than pragmatic, especially in training institutes. Toward the end
of his life, Fairbairn (1952) opted to give up using the couch and
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replaced it with a chair for the patient that was placed somewhat
parallel with his chair and yet slightly angled so as to convey the
impression that they were each focusing on the same thought. Perhaps
Fairbaim's famous patient, Harry Guntrip, the great egalitarian, might
have influenced him in this regard.
If we remove the ritualized aspect of the use of the couch, then we
may ponder such considerations as:

(1) Should the analytic patient be restricted to the couch throughout

the analysis or might he or she be able, or even encouraged, to sit
up from time to time or on clinically indicated occasions—and,
if so, what are those occasions?
(2) Should psychotherapy patients be encouraged to use the couch?
This is a cogent issue at present since so many psychoanalyti-
cally oriented or informed therapists who have couches are
practicing today and use them for a wider and wider group of
patients who are not in formal—or maybe even legitimate—
analysis. However, the issue pertains especially to those who are
in legitimate training, are graduated from approved institutes, or
both. We need to review the indications and contraindications of
the use of the couch in light of the trends in current practice.
(3) With the preceding ideas in mind, can the couch be justified or
even indicated in doing psychotherapy at frequencies less than
four times a week? I myself frequently suggest the couch for
many psychotherapy patients who come less often than four
times a week. In my opinion, they are, in each case, potentially
analyzable but cannot come more frequently because of money,
distance, or other external factors. One of my most meaningful
and successful cases was that of a young woman whom I treated
on the couch once a week for three-and-a-half years. Put more
REASSESSMENT OF THE COUCH 403

succinctly, the rationale for the use of the couch in analysis and
in psychotherapy is in need of reconsideration.
(4) Another interesting aspect of the issue of the couch lies in the
nature of newer furniture. Some therapists have placed two
Swedish rotating lounge chairs in their offices, thereby allowing
the patient to lie down, sit up, or rotate away from or toward
the therapist. Is this yet another consideration that deserves
attention?
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I now discuss some clinical vignettes that reveal individual reac-

tions to the use of the couch:

(A) This patient is in the psychotherapy field and consequently

entered treatment with knowledge and preconceptions about the
couch, which were dealt with at great length sitting up in the
initial stages of the therapy. Once I thought he was ready for the
use of the couch, I indicated that he might now move over to it.
He did so and then quickly became aware of a sense of mystery
and awe—one in which he felt small and considered me gigantic
and forbidding, having a preternatural bearing. The transference
aspects of this defensive idealization of me consequent on the
infantilization of him precipitated by his moving from the chair
to the couch was interpreted and brought relief.
(B) This patient is a well-known actor who had been adopted when
he was an infant. The lying-down position was equated by him
with his birth mother's leaving him. It took us some time to work
through this fear. He was terrified in the meanwhile about any
silence on my part, silence being equated with abandonment.
(C) I have had two patients who had suffered from similar problems
who had similar reactions to the use of the couch. Each demon-
strated a marked schizoid tendency in his personality. I intro-
duced each to the couch early in the analysis, only to encounter
the same reaction. Each felt lost, abandoned, dissociative, frag-
mented, alone. I then had each sit up in the chair and conducted
the analysis face-to-face for a couple of years, by which time
each spontaneously asked to be allowed to use the couch once
more. The spontaneity of the requests was interesting. Not only
had they acquired sufficient ego strength in the meantime to be
404 JAMES S. GROTSTEIN

able to use the couch, but they had also become gradually
dissatisfied with what they felt was the superficiality of the
sitting-up treatment. They seemed to have discovered the differ-
ence and eventually longed to return to the couch "to go deeper."
(D) L. G. is a patient who also is a psychotherapist. She is not a
psychoanalyst herself and uses the sitting-up position for her
own patients. I began seeing her twice a week at the start of the
treatment and therefore used the sitting-up position. As we
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proceeded, it became apparent that there were deeper issues that

she felt needed to be contacted, so she asked for the use of the
couch, and I acceded. Later she started formal analysis with me
and came four times a week. As time wore on, she developed the
pattern of starting the analytic session by sitting up on the couch,
reporting her "diary" day residue—as if to "debrief her self to
me—and then asking, "Do you want to do a little bit of analy-
sis?" I ultimately came to realize that she needed and wanted
analysis but was afraid of its regressive pull and sought this
ritual to break her fall, so to speak. We came to realize that the
"fall" was into an inner "black hole."
(E) There are a few patients I have seen once a week, the infre-
quency of sessions due entirely to external reasons (money
and/or distance), with whom I employed the couch. In these
particular cases, I believe that I was able to conduct psychoanal-
ysis quite satisfactorily and to achieve significant results. It was
remarkable to me how each of these patients was able to achieve
transference neuroses and to carry over the unconscious themes
from one week to the next.

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