For those psychoanalysts who use the couch as a tool in the office, the act of lying down on it can be of great significance to both doctor and patient. For the doctor it can be a signal that the patient trusts him and is willing to explore his inner demons and bring them to the surface to be examined and faced head on. It is, in short, a signal that the patient is prepared to begin the healing process.
To understand this, one must consider the various defense mechanisms that are being overcome and the internal struggle that a patient is going through on different levels of awareness. At the very top level of awareness is physical comfort, the patient needs to feel relaxed and open to the contemplation of his life and the meanings of his actions. This relaxed, contemplative mood is almost impossible to achieve with uncomfortable factory or classroom standard-issue furniture.
Therefore all the furniture in a psychoanalyst’s office is designed to put client at ease and shunt aside barriers to open conversation. You must bear in mind that no analyst worth his fee is going to try to delve deeply into the conscious and subconscious mind of a client until he has established a rapport with the client and there exists a psychological connection between them. That connection must include a deep-seated trust in the analyst for no progress can be made if the patient does not believe that the secret life of his mind is safe in the hands of the doctor. Once that trust is well established and a habitual element in the mind of the client then the psychoanalyst can move on to sessions with the couch as an ingredient in the mix of tools at his disposal.
It must be understood how important the issue of emotional and psychological vulnerability of position is when a client first agrees to lie down on the couch. One does not willingly lie down with the enemy! It is ingrained into our forebrains by a million or more years of evolution. Once that level of trust has been established the psychoanalyst is truly in a position to probe the mind of the patient.
But it is not only the doctor who benefits from the freedom of non-eye-to-eye contact. The doctor is now free to make notes without endangering his rapport with the patient while the patient is free to let his mind wander down paths he might not take while sitting up face-to-face with the doctor. The patient can and should develop the feeling of confiding to a friend. A friend who is not there to judge him but only to be there as a confidante in a troubled time should he be needed. And that feeling from the patient can be one of the most potent tools available to the psychoanalyst.