On the Couch

Many years ago, the New York City subway was plastered with enormous couch posters, part of a 1991 ad campaign by the Archdiocese of New York. They bore the caption (some in English, others in Spanish), “Some people find the same peace of mind sitting in a pew. Come home at Easter. The Catholic Archdiocese of New York.” As a young psychiatrist and candidate in psychoanalytic training in Manhattan, I was taking the subway four times a week to my analyst’s office to lie on just such a couch. These ads were obviously not aimed at psychoanalytic trainees like me. Who, I wondered, comprised the target audience? And why was the Church so confident that subway riders would easily decode the image in front of them, and immediately understand the implied choice between couch and pew?

The couch endures as a cultural icon, a symbol of self-reflection and healing, a shorthand for the therapist in cartoons and movies even as the popularity of psychoanalytic treatment wanes. We could say the couch is more resilient than the field of psychoanalysis itself, and I would add that its iconic status in the general culture contrasts with it being held in increasing suspicion by some contemporary analysts, who display growing ambivalence about it, or even scoff at the tradition of the patient’s recumbence, seeing it as a relic of a more authoritarian era, a power play on the part of the analyst that unnecessarily regresses or infantilizes the patient and supposedly blocks the path to authentic emotional engagement. I find such a priori assertions problematic. They’re not based on any real knowledge. There’s no evidentiary basis either for mandating or disparaging use of the couch. The research simply hasn’t been done. We can’t know in advance which patients will find it liberating, and which will find it too discomfiting.

Freud famously said that he got analysands to lie on a couch because he couldn’t stand being stared at all day, but he never explained why recumbent posture should be preferred to simply arranging the chairs so that analyst and patient don’t face each other. Freud’s couch, heavily decorated with rugs, pillows, and blankets and surrounded by his extensive collection of antiquities, has the look of a Turkish divan. It speaks volumes about its owner’s taste and interests. Most contemporary analysts have distanced themselves from Freud’s aesthetic, heavily inflected with the romantic and archeological motifs so popular in his day, preferring the sparer, more spartan couch usually seen in cartoons and illustrations today. But even among analysts who have forsaken the couch as part of their treatment technique, many retain one as part of their office décor.

Pondering the disjuncture between the couch’s iconic status and its apparently diminishing role in analytic technique led me to realize that the origins of its use in psychoanalysis have never been fully explored. The analytic literature is strangely silent on this topic. Following Freud, the couch became a fixture of analysts’ offices, but no one seemed to know why.

I decided that since analysts haven’t been able to articulate a compelling clinical rationale for recumbence, it would be better to delve into the social history of posture to find explanations for the couch’s cultural importance as a symbol of self-awareness. Starting with a look at the Greek and Roman customs of reclining dining, I found that far from connoting passivity or submission to medical authority, recumbence in social settings has long served as an expression of freedom, pleasure, luxury, and intimacy. Evolving ideals of comfort and social intimacy reflected in furniture history, clothing history, manners, and the healing arts converged in the nineteenth century such that it became thinkable to lie down in the presence of another person to talk. Even though some professionals today frown upon its use, the couch retains its significance in the public lexicon of symbols for interiority because it resonates so strongly with these cultural ideals.

It’s true that no one can claim to know with any degree of certainty for whom or for what types of problem the use of the couch is best suited, and there is no substantial body of empirical research on posture, frequency of sessions, or duration of psychoanalytic treatment. I continue to recommend using the couch to most patients I treat in analysis. But I don’t insist on it, and I always try to ascertain the patient’s interest first. Ideally, both analyst and patient are better able to access deeper layers of thought and feeling once freed from having to attend to the usual social cues of face-to-face interaction, but only a trial of analysis on the couch will tell. Good analytic technique calls for flexibility and sensitivity, not for the doctrinaire insistence on one posture or another. At the same time, it seems fair to assert that reclining for the purpose of talking to someone is for many people a uniquely powerful experience that has no parallel anywhere else.

Praise for On the Couch:

"In this penetrating, imaginative, witty book, Nathan Kravis traces the significance of the psychoanalytic couch, drawing on philosophy, history, Freud’s own writings, and evolving fashions in decorative arts. What results is a penetrating commentary on how the eternal truths of psychoanalysis intersect with fashion and happenstance. This psychoanalysis of the couch itself is written with both humor and insight.”
— Andrew Solomon, author of Far from the Tree

"Nathan Kravis, who is both a practicing psychiatrist with psychoanalytic training as well as a distinguished historian of psychiatry at the Weill Cornell Medical College, has produced a masterpiece of visual history rooted in his reading of Freud."
— Sander L. Gilman, Bulletin of the History of Medicine, 2018