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As Dr. Dunn has told us, the analysis of Miss X was complicated from the onset by Ms. X's reaction to the suggestion that she use the couch. Now, patients are frequently made anxious by the idea of the couch; as one patient told me, in her mind it seemed like sliding down a razor blade. Nonetheless, my patient did try the couch and, like a number who are initially fearful, she found it helped her speak more openly. Of course, there are patients who flatly refuse to use the couch, and who go on to have a successful analytic experience face to face. Both Maryanne Goldberger (1995) and Thomas Ogden (1996) have written papers to that effect. But whether a patient uses the couch or not, it usually does not become as important an aspect of the analysis as it was in the work with Ms. X.
What made it so important? First, I think Dr. Dunn was caught in a not uncommon dilemma for young analysts, one that was created by a recommendation becoming a requirement. Perhaps he believed (or had been taught) that for analysis to take place, a patient must lie on the couch. Many of us who analyze children and adolescents do not share this belief, and though we prefer our adult patients to lie on the couch, we are not thrown by their refusal. I cannot deny, however, that the couch is a significant aid to the development and analysis of unconscious fantasies and conflicts as revealed via the transference. Using the couch is like watching a movie or play in a darkened theater, one loses oneself in the action. Off the couch, it is as if the lights were on, and one is distracted from the ongoing drama, reminded again and again by seeing the audience that it is only a play, only a movie.
However, though the couch is useful, it is not a requirement for an analysis to be successful, just as paying a fee is not a requirement