Monday, May 13, 2019

“Please, come in, make yourself comfortable” (said while gesturing to the couch and chair) [Updated]

Freud's consulting room
Along with the psychological climate of psychotherapy, the physical setting represents a standard medium for therapist expression in general and for the expression of power in particular [we’ll have to set aside here several definition of power or the various conceptions and types of power, in both negative and positive terms]. ‘Physical setting’ refers to the arrangement and contents of the office space as well as the visible aspects of the person (therapist) and his or her accoutrements.

Characteristics of the setting often have important symbolic meanings for both client and therapist. In the eyes of the participants, characteristics of the setting typically express power, nurturance, or other salient phenomena related to therapeutic behavior.

Physical setting characteristics probably exert greatest influence early in psychotherapy, prior to the development of a deeper and more thoroughly articulated therapeutic relationship. Once power communications are finding more direct if not verbal avenues for expression, these background concerns tend to be less pervasive in the minds of the participants.

The physical setting in psychotherapy tends to intersperse power symbols with more unintentional and less influential setting aspects. Particularly in reference to personal items, distinguishing between attempts at power and less willful interest is rarely clear or facile. [….]

One of the most glaring manifestations of power in a therapist’s office is the seating arrangement; one of the most power-laden of these is the psychoanalytic couch, which serves as a famous illustration. The couch is an expression of power to the analytic patient in several ways. With a gentle persuasiveness, the presence of the couch may communicate that all of a patients body, posturing, and movements, or the lack of them, are open to the interpretations of the analyst. Similarly, the couch may serve as muscle relaxer or pain reliever, and thus become a manifestation of an analysts love along with his or her power. In other words, it reflects unspoken and inherent power to comfort.

Yet, perhaps what is even more apparent is the relative positioning of the patient and the therapist. The upper-lowerseating arrangement between vertical therapist and supine patient conveys a hierarchical and uneven relationship [the first adjective strikes me as overstated if not false]. With the use of the psychoanalytic couch, the patient falls under the doctor’s examining influence and resembles the reclining infant dependent on the mothers care. In fact, the couch may render the patient more pliant to the therapists suggestion or intimation [interpretation?]. Other authors, less predisposed toward the couch, have also observed that it may encourage a sedentary manner, passivity and atrophy as well as relaxation. These warring perspectives exemplify the embittered controversy that continues to surround discussion of the psychoanalytic couch. [….] – From Chapter 6, “Structural Manifestations: The Symbols of Power,” in David Heller’s Power in Psychotherapeutic Practice (Human Sciences Press, 1985): 109-121. 

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It is often after I’m well into a book that something is discovered deemed worth sharing; today’s case is an exception. The material in question is from the first pages of The Art of Psychotherapy (1st ed., 1979, 2nd ed., 1990) by the late Anthony Storr* (18 May 1920 – 17 March 2001), English psychiatrist, psychoanalyst and author of over a dozen books. The chapter is titled, appropriately enough, “The Setting,” and it illustrates but one of a “what appear to be inessential details” in psychotherapeutic practice that “are in fact important.”

“… [T]he room in which the therapist sees patients, and the way that room is arranged are factors which ought to be taken into consideration. In private practice, one is free to arrange and furnish one’s consulting room in any way one likes. In hospital practice, junior doctors are lucky if they have any choice in either the location of the room in which they see patients or in its furnishing or appearance. In spite of this, I shall describe how I think a room in which one is to practice psychotherapy should be; and I would urge all psychotherapists in hospitals and outpatient clinics to insist that these basic requirements are met by the authorities, and to express dissatisfaction when they are not. At present [i.e. in 1979], it is often easier to get money for expensive electrical devices, video-tape recorders, computers and the like than to see that a number of rooms in a psychiatric hospital are properly furnished and sufficiently comfortable for psychotherapy to be carried out.

Ideally, a room in which psychotherapy is to be undertaken should be furnished as follows. First, there should be a comfortable chair in which the patients can relax. Many patients will be so tense at first that they will be unable to make proper use of such a chair, but one hopes that as the therapy progresses they will increasingly be able to do so. Being perched on the edge of a hard chair of the kind too often provided for outpatients is not conducive to personal revelation [or even simply convivial or ‘healing’ conversation], and may put the patient at a disadvantage compared with the doctor, who will almost certainly be more comfortably seated.

Second, there should be a couch on which the patient can lie down. This should not be an examination couch of the kind which physicians use for physical examinations, but something far more comfortable. When I was in private practice I used a divan bed which proved satisfactory. If suitably covered, this does not look like a bed, to which some patients might object and which others might welcome with misplaced enthusiasm. It should have at its foot end an extra piece of the same material in which it is covered, which can easily be removed for cleaning. This enables the patient to lie down without having to take off his shoes, which might otherwise dirty the cover. At the other end of the couch should be a number of covered cushions which the patient can arrange in any way that he finds comfortable.

The couch should be so placed that the therapist can sit at the head of it, out of sight of the patient, without having to rearrange the furniture every time the couch is used.

Many psychotherapists never follow the psychoanalytical practice using such a couch …. But I have found it useful with some patients; and I prefer to have it as an available alternative which the patient can use if he finds it easier to relax when lying down, or easier to talk if he is not face-to-face with the therapist.

Office in psychoanalysis
In most clinic rooms, the doctor will be provided with a desk, and with a more or less comfortable chair in which he will sit behind it. This arrangement has the disadvantage that it immediately puts the doctor in a ‘superior’ position vis-à-vis the patient; but does enable the doctor easily to take notes if he wishes to do so. When one has had the opportunity of getting to know a patient really well over a period of time, taking notes may be superfluous: but most doctors will want to do so initially, though they should not do so if the patient objects. Note-taking should be as unobtrusive as possible, in order not to interrupt the patient’s discourse.

It is important that, if the doctor is sitting behind a desk, the furniture be so arranged that the patient is not immediately opposite him, with the desk intervening like an impassible barrier. Business tycoons use their desks as a means of intimidating their juniors, which is why they often insist upon having unnecessarily large expanses of mahogany between them and their ‘inferiors.’ It is generally possible so to arrange the furniture that, if a desk is used, the patient’s chair is placed to one side of it, so that there is little feeling of a barrier. Which side is chosen depends on whether the therapist writes with his left hand or his right. I happen to write with the right hand, and therefore place the patient on my left. This enables me to scribble notes if I wish to do so, whilst at the same time facing the patient and being able to say things directly to him without turning away or looking down. [….]

In hospital, it is probable that the therapist, especially when he is beginning, will have little choice in how the room is decorated or in what other furniture may be there. Hospital rooms are often drab, suggesting impersonal officialdom and the ‘Welfare’ State. I do not believe that it is necessarily more expensive to decorate a room in such a way that it gives the impression of warmth and friendliness. Where the therapist is in a position to exercise his own personal choice, he may well like to hang some pictures on the walls, and fill the bookshelves (if there are any) with his own books. This is entirely reasonable; but I think it important, for reasons which will emerge later, that the room should not contain anything which too stridently asserts the therapist’s tastes or which is likely to reveal a great deal of his personal life. [….]

Many professional people like to bring reminders of home into their offices by displaying photographs of their wives [or husbands or lovers] and children [and pets!]. I think it is undesirable for psychotherapists to do this. When patients become deeply involved in the therapeutic process, they are likely to experience powerful feelings of love, hate, envy, jealously and the like toward the therapist [as in ‘transference’]. Explicit reminders of the therapist’s life outside the consulting room of the kind provided by family photographs may inhibit the expression of these feelings. Moreover, the patient will have phantasies about the therapist’s personal life; and the content of these phantasies may be important in understanding the patient. [….]

Office in psychoanalysis 2
It is important, if possible, the room should be quiet. Extraneous noise is not only disturbing in itself, but also gives rise to anxiety on the part of the patient. For if noise from without can come into the room, it is likely that sounds from within can be heard outside it. Nothing is more inimical to frank disclosure [let alone, ‘free association’] than the belief that one may be overheard. Most hospital rooms will contain a telephone. It is important that, during the time of the therapeutic session, the therapist does not make or take telephone calls [it is quite remarkable that there is seen the need—likely for sufficient reason—to make this particular proscription explicit; although in the time of the smartphone, it may be that much more urgent]. This is usually possible to arrange, except when the doctor is on call for emergency duties within the hospital. In my view, the doctor practicing psychotherapy should do so only on those days on which he is not on call for emergencies, or else ensure that a colleague covers for him during the time during which he is practicing psychotherapy. [….]

It is often hard to convince telephone operators and secretaries that one really must not be disturbed during psychotherapy sessions. ‘But Dr. X said it was urgent,’ they will protest. Calls are very seldom so urgent that they cannot be postponed for fifty minutes (to put it at its worst), or transferred to someone else. When I was in practice in London, I was so insistent upon not being disturbed what when a call came through from a doctor in Australia, my receptionist told him to ring back later. I congratulated her upon her firmness [I immediately thought here of Deborah Fiderer (Lily Tomlin), President Josiah Bartlet’s second private secretary on The West Wing]. It is important so to arrange the times of psychotherapeutic sessions that there is a gap of ten minutes or longer between patients. This enables the therapist to deal with telephone calls or other matters which may have arisen during the session with the last patient.

All these things are much more easily arranged in private practice than in hospital practice. My view is that, whether the patient is paying for treatment directly [through] private fees, or indirectly by the taxation which finances the Health Service, he is entitled to feel that the time he spends with the therapist is his time; and that this should not be diminished by interruptions.”

Office in psychoanalysis 3
* From his Obituary notice in The Guardian: “Anthony Storr … was Britain’s most literate psychiatrist. A prolific author, journalist and radio and television commentator, he was widely respected as a fount of wisdom and good sense in a profession not particularly noted for such qualities [?!]. Like other kind and compassionate men, he was no stranger to suffering at formative stages of his life.

Born in London, Storr was a solitary, friendless child, plagued by frequent illness, including severe asthma and septicaemia, from which he nearly died. He was the youngest of four children, separated by 10 years from his closest sibling. His father, Vernon Faithfull Storr, sub-dean of Westminster Abbey, was 51 when Anthony was born, and his mother, Katherine Cecilia Storr, was 44. They were first cousins, and their consanguinity probably accounted for his asthma, from which he, like two of his siblings, suffered for most of his life. He also seems to have inherited from his mother a tendency to occasional episodes of depression.

Growing up in the privileged seclusion of Dean’s Yard, Westminster, as virtually an only child, Storr was particularly affected by the trauma, shared by most boys of his class and time, of being sent away to a boarding prep school at the age of eight. There, and later at Winchester College, he was bitterly unhappy. Having been deprived of a childhood peer group in which to learn the skills of comradeship, he was ill-prepared for the rigours of boarding-school life. Extremely slow to make friends, and showing little proficiency for games, he was bullied, and made only average academic progress. Though utterly miserable, it never occurred to him to complain to his parents, or attempt to run away, because boarding school was then a fact of life. But the sense of being a loner never left him, and was to affect the course of his career, as well as the content of his books.”

Major Sidney Freedman
(Dr. Sidney Theodore Freedman, played by Allan Arbus in the television series M*A*S*H, is a psychiatrist frequently summoned in cases of mental health problems.’ Sidney represents conditions for psychotherapeutic practice well outside the scope of Storr’s suggested considerations and instructions for the spatial setting of psychoanalytic therapy.)

Further Reading: Chapter 6, “Structural Manifestations: The Symbols of Power,” in David Heller’s Power in Psychotherapeutic Practice (Human Sciences Press, 1985): 109-121.


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