When I work with individual patients, at the start of treatment, I usually ask them to lie on the couch (with the exceptions of drug and alcohol abusers or victims of sexual abuse who tend to regress too much under these conditions and because of overstimulation suffer a relapse of symptoms). It has been my experience that lying down fosters looking inward rather than focusing on my reaction. If a patient balks at the idea of lying down, I don’t insist because pressuring would turn the treatment into a power struggle, rather I explore with them their objection to lying down. Recently, this process led to a rather dramatic uncovering of traumatic material, material that may have not emerged for a long time, had I not suggested lying down at the beginning stage of treatment.
A middle-aged black woman sought treatment for depression. She only had a vague sense of why she was depressed but she was able to identify when the depression began. “Martha” said that things started to change about six months ago, when her daughter left for college. The first session was devoted to an intake history of her move to this country, better opportunity for advancement, she said, her failed marriage, career starts and her life as a single mother. The second session was delayed for several weeks because she broke it saying that she ‘ forgot’ to call to cancel. When I asked her why it was okay with her to forget to call, she replied: “I’m only human”. At the beginning of our next session, I broached the topic of lying down. When I asked her if she would lie on the couch Martha vigorously shook her head–No! When I asked why not, she said that she must always be on the alert. This was a rather startling response. Most patients balk because they say that they want to see me; they want to see my reaction or even they want to make sure that I don’t fall asleep. My first thought was that she had been sexually abused and needed to be hyper- vigilant of her surroundings, perhaps particularly so, around a male. When I asked, she said that she had not been sexually abused. For the moment, I dropped the subject of lying down and told her the five subjects that should be covered in each session: 1. recent past 2. distant past 3. dreams 4. sex life and 5. feelings about the therapy. Martha spoke of having been born in a poor village in Africa. Her mother died when she was a young girl. She never knew her father and so she went to live with a cruel aunt who treated her like an unwanted step-child, favoring her own children over her. Her emotional life was saved, she said, by her maternal grandmother who adored her and whom she adored her.
At the third session, I revisited the idea of lying on the couch. This time she reluctantly agreed. When she first lied down, I asked her how it felt. She said that she felt uncomfortable. I asked why. She said that she didn’t know only that there was a vague sense of unease. As she was speaking about her current job, I shifted around in my chair behind her. As I moved slightly, she immediately bolted upright, as if she had just received a painful electric shock. She jerked her head around and looked at me in horror. “What happened?” I asked. She said that I startled her and she became afraid. ” Afraid of what?” I said. And then it all came pouring out. After her mother died and she moved to her aunt’s house in a war torn part of her country, she witnessed horrible things. She had memories of walking with her friends down stretching of road that smelled terrible and seeing fields of either side covered with flies. The flies were atop the bodies of hundreds of people murdered by the rebels. Her friends would joke about the flies and would tease her, threatening to toss her into the fields as they walked. Then she recalled being at her aunt’s home one night and hearing a woman next door screaming for help. She was being raped. Martha was terrified for the woman and feared that she would be raped too. I was shocked by the intensity of the violence she had witnessed and told her that she had been traumatized.
It’s too early in the therapy to know how these traumatic experiences have been integrated into Martha’s life. However, I am certain that their revelation would have not emerged so soon had she not been on the couch. The regressive power, to unearth repressed memories, by lying down and talking in treatment was once again made clear to me in this case.
