The expression face-to-face situation is used to describe the sitting arrangement in psychotherapy, as opposed to psychoanalysis where the patient is on the couch facing away from the psychoanalyst.
Sigmund Freud's prescription is clear as early as 1904 when he wrote, in "Freud's Psycho-Analytic Procedure," "Without exerting any other kind of influence he [the analyst] has them [patients] lie down in a comfortable attitude on a sofa, while he himself sits on a chair behind them outside their field of vision" (p. 250). He was even more explicit in 1913 when he wrote, in "On Beginning the Treatment (Technique of Psycho-Analysis)," "I must say a word about a certain ceremonial which concerns the position in which the treatment is carried out. I hold to the plan of getting the patient to lie on a sofa while I sit behind him out of his sight. This arrangement has a historical basis; it is the remnant of the hypnotic method out of which psycho-analysis was evolved. But it deserves to be maintained for many reasons. The first is a personal motive, but one which others may share with me. I cannot put up with being stared at by other people for eight hours a day (or more). Since, while I am listening to the patient, I, too, give myself over to the current of my unconscious thoughts, I do not wish my expressions of face to give the patient material for interpretations or to influence him in what he tells me. The patient usually regards being made to adopt this position as a hardship and rebels against it, especially if the instinct for looking (scopophilia) plays an important part in his neurosis. I insist on this procedure, however, for its purpose and result are to prevent the transference from mingling with the patient's associations imperceptibly, to isolate the transference and to allow it to come forward in due course sharply defined as a resistance" (pp. 133-134).
The patient's obligation to lie down, according to the fundamental rule, is the second of the two main conditions of treatment that Freud expressed to the Rat Man, who quickly attempted to transgress it (Freud, 1909). Sixteen years later, Freud returned to this issue with Smiley Blanton, as the latter's Diary of My Analysis with Freud (1971) reveals: "The position is only a matter of convenience, but one point remains essential: The analysand must not see the analyst's face. If it were otherwise, the analyst's expression would influence him." In The Fabric of Affect in the Psychoanalytic Discourse, André Green writes: "Analytic speech is speech delivered lying down . . . addressed to a hidden partner " (1999 , pp. 232-233).
The broadening of the types of cases in which psychoanalytic treatment has been deemed possible (psychosis, drug addiction, borderline personality disorders, behavioral disorders, and so on) has modified this previously inflexible rule and led to proposals that certain treatments take place face-to-face, known as "psychoanalytically inspired psychotherapies" (Held). Such therapies have been seen as a means of controlling the narcissistic regression to which the reclining position on the couch is conducive, along with the feelings of depersonalization, overwhelming anxiety states, or mechanisms of defensive rigidification it can entail. A more rational verbalization is thus encouraged; only psychotics are truly uninhibited in communicating their delusional fantasies in face-to-face situations. Better mastery over terrifying impulses to destroy the object can be achieved because of the constant possibility of seeing that the object—here represented by the therapist via the transference—is still present and intact (which at times necessitates, on the part of the therapist, a no less effective mastery over his or her own countertransferential anxieties).
The visual gaze intervenes less often as a satisfaction of voyeuristic or exhibitionistic drives than as a testament to the vigilance and security felt by a patient who does not have to fantasize the presence, behind him or her, of an invisible power who sits in judgment and can at any time, without warning, unleash punishment or destruction. The making or avoidance of eye contact is a harder burden for the therapist to bear than for the patient, as Freud noted; behind their elaboration, the crudest countertransferential affects are liable at any time to manifest themselves in body language, facial expressions, or a change in attitude that patients unfailingly perceive and interpret.
Can psychoanalytic treatment, in the full sense of the term, take place in the face-to-face situation? Opinion is divided on this issue, although the majority of authors believe that the blocking of fantasies and the difficulty of developing a transference neurosis within a face-to-face situation make it unlikely that an authentic psychoanalytic process can be established. Certain practitioners begin treatment of difficult cases with a period of face-to-face interaction, or insert into classical treatment an interval of face-to-face interaction, which may vary in length, when excessive anxiety makes it dangerous to proceed with treatment within a strictly defined psychoanalytic setting. Such an approach can also be put forward with patients who return to see a psychoanalyst after having finished with classical analysis—a situation that is now increasingly in demand—and, in these cases, must address the often excessive length of treatment and the maintenance of an idealized transference (whether positive or negative) that has been insufficiently analyzed.
In current practice, it is increasingly common for psychoanalysts to interact with patients face-to-face, particularly when only temporary support is required or because a current life event—a trauma, for example—calls for a type of help that remains on the surface of the psychic processes, "at the level of the ego," to use an accepted phrase.
In the face-to-face situation, where all the parameters of a permanent erotic-aggressive confrontation seem to converge to produce a pure and simple repetition of a patient's archaic relational modalities, it is above all important that the psychoanalyst's listening and physical perception of verbal and intraverbal reality, beyond any reductive fantasmatic project, bring the patient a progressive and profound refutation of their life-sustaining certainty that "nothing can change" and that he or she would run tremendous risks by giving up habitual defenses.
See also: Analytical psychology; Psychoanalytic treatment; Psychotherapy.
Blanton, Smiley. (1971). Diary of my analysis with Freud. New York: Hawthorn.
Brusset, Bernard. (1991 May-June). L'or et le cuivre. La psychothérapie peut-elleêtre et rester psychanalytique? Revue française de psychanalyse, 55 (3).
Freud, Sigmund. (1904a ). Freud's psycho-analytic procedure. SE, 7: 247-254.
——. (1909d). Notes upon a case of obsessional neurosis. SE, 10: 151-318.
—— (1913c). On beginning the treatment (Further recommendations on technique of psycho-analysis I). SE, 12: 121-144.
Green, André. (1999 ). The fabric of affect in the psychoanalytic discourse. London and New York: Routledge.
Held, René. (1964-1965) Rapport clinique sur les psychothérapies d'inspiration psychanalytique freudienne. Revue française de psychanalyse, 28 (special number).
Weissman, Stephen M. (1977). Face to face: The role of vision and the smiling response. Psychoanalytic Study of the Child, 32, 421-450.