I think Freud initially came up with the idea of the couch because he got tired of being stared at. He had oral cancer and this was not a pleasant thing to be looked at, so I think that was part of it. He discovered that a different part of the brain is accessed when you lie down, closer to the unconscious, closer to the dream state, and it’s more relaxing.
There are visual cues that go back and forth between the two of us when we are face to face, and that affects the dialogue. The thought is if the patient is looking the other way, comfortably, that I’m staying out of the conversation unless I choose to be there, unless they choose to put me there as opposed to, unconsciously, I smile at something and that affects where they’re going.
I don’t ever insist on the couch, I let people decide. I may tell them the pros and cons and say why it might be helpful, why it might not be helpful, but I have much of my practice on the couch and much of my practice sitting in a chair. I don’t force people and I don’t tell people they have to do something.
~ Rafael Sharón, NCPsyA, SCPsyA, Psychoanalyst in Princeton NJ