You may wonder if you were to go to a psychiatrist office for psychotherapy whether you would be expected to lie down on the couch. The couch is an important symbol in the cultural concept of what psychiatry is all about.  It is the feature of Hollywood movies and comedians’ jokes.  

When they first walk into my office, some of my patienst will ask me if other patients lie down on the couch.  What do they imagine happens when you lie down on one?  Clearly it implies a certain degree of surrender, an expression of trust, if you will.  Lying on your back you are in a poor position to either fight or flee.  You are in effect subjecting yourself to the psychiatrist’s will.

The psychiatrist's couch dates back to the days of Sigmund Freud. He originally used it as an aid to hypnosis.  When he gave up that modality in favor of stream of consciousness talk therapy, he continued to use the couch to reduce dependence or attachment to the analyst.  Thus they would not be distracted reacting to his facial expressions. They would pay more attention to their own internal stimuli and the words that erupted from their unconscious. 

Following in Freud's pattern some psychoanalysts continued the practice of having the patient's lay on a couch, staring up or slightly ahead while the psychiatrist sat behind them. The type of therapy that was done in psychoanalysis was based on a stream of words which would be associations to the unconscious.  The anxiety about psychiatry is really nervousness and fear of what might be discovered in the mysterious process that occurs there.  Will the psychiatrist discover some dark secrets of which even the patient is unaware?

The attachments or antagonisms that the patient formed to what they imagined the psychiatrist to be, which is called transference, often became the focus of the psychoanalysis. Some patients imagined that the psychiatrist was the ever-present father figure. Others imagined the psychiatrist as a favorite uncle or an older sister. Having the patient react to the psychoanalyst and the positive and negative feelings that they generated, served as an opening to how the patient’s relationships worked in the real world. It is through these examinations of the psychoanalyst would come up with ideas about the patient's defense mechanisms: the ways that they operated to protect themselves against unconscious threat posed by others in their life.

      Nowadays most psychotherapy is done according to a different protocol. Psychiatrists and other counselors generally sit in comfortable chairs facing the patient. The rooms are often well lit instead of dark dungeons of mysterious, subconscious, sweltering atmosphere. There may be a couch but if so it is for families to sit upon. In my offices there are couches but in 20 years of practice only two people have ever laid down to talk to me recumbantly. For them it was an act of trust but more so of comfort.  The couch is now really a sofa.

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