If your office has only one chair in which the patient can sit, this column won’t be particularly useful to you. If you have several options, but have only directed the patient to one of them, or if, as I do, you let the patient choose a seat, I think you’ll find this helpful in your increased observation of non-verbal patient behavior.

To give you a context for this discussion of another patient behavior (see Tissue Behavior, in the Fall,’06.issue of IP), and absent a schematic drawing, I will have to paint a word picture of the layout of my office. Envision, if you will, a 12 x 14 room with a bay window on one of the long walls, with my desk set into the bay. It was the dining room of an 1890’s Victorian house, and has a beautiful leaded glass cabinet opposite the bay. There is a parson’s table with 2 wooden chairs against the short wall, opposite a window. A 3-cushion leather couch sits in front of the window. There are 3 identical swivel tub chairs. Mine, with its’ back to my desk and just behind the one arm of the couch (in a tribute to analytic psychology!) is distinguished by having a low hassock in front of it. The other two face my chair: one directly and the other, slightly further away, at an angle and closer to the door. There is a table with a clock on it between those 2 chairs, and another between my chair and the end of the couch. (And, of course, a box of tissues on each.)

When I see a patient for the first time, I escort her from the waiting room into my office. I gesture widely and suggest that she sit wherever she will be comfortable. (My chair is almost always perceived as such, not so much because of the hassock, but because there’s a file folder and pen on the seat, awaiting the session.) Years ago, when I saw kids, they might playfully run in and sit in my seat. But an adult has never done that, although some have verbalized a fantasy of doing it. In any event, the new patient has 5 available choices: 2 tub chairs and 3 couch cushions.

The most commonly chosen seat is the one directly across from me. So when a new patient chooses that one, I am unlikely to make much of it. I actually like that choice because I can sit straight ahead and use the hassock. (I read long ago that it’s unhealthy to sit with your legs crossed all day, and the only way to stop myself from doing that is to use the hassock.) Additionally, I can see my clock easily, without the patient thinking that I’m constantly turning my head to see if the session is almost over.

15-20% of patients choose the other tub chair. It’s the first one they come across upon entering the office. It’s the closest to the door. I wonder whether this is an impulsive patient, who takes the first choice available, an anxious patient who doesn’t want to venture further or wants an easy escape route, or a more guarded patient who doesn’t want to approach me head on. Over time, I will learn the answer, but that first behavior gives me a clue. And I should note that once a patient chooses a seat, it’s his for the duration. I can only think of one patient, in all my years of practice, who decided to change seats after several months in therapy to see if that would change his progress in treatment. Interestingly, he was a man who accepted very little responsibility for his behavior and looking for the seat to make the difference, rather than he himself, was entirely consistent with his character. 10-15% of patients choose a place on the couch. (No one, by the way, comes in and just lies down!) A small number sit at the foot of the couch, as far from me as they can get, and at the most awkward angle. These are generally the most guarded people, for whom opening up is the most difficult. As they get more comfortable with the therapeutic process, they don’t pick a different seat, but they perch on the edge of the couch in a way that they can better make eye contact with me. Those that choose the middle cushion are edging closer to me. The seat places them closer than either of the tub chairs. So I assume they are a milder version of the few patients who chose to sit in the corner of the couch, as close to me as they can get. These are inevitably the most dependent, and often the most regressed, of my patients.

Their choice of seat alerts me to proceed with caution, not move to fast, not challenge the defenses too quickly. These are the patients who are most likely to need supportive, rather than in-depth treatment, to first build ego strength. Interestingly, a male patient has never chosen that seat. I don’t believe it’s because my male patients are all that much healthier than my female patients. Rather, the gender constraints preclude a man from getting too close to a woman whom he doesn’t know. In fact, if would be highly significant if a man did override that constraint and choose the seat in the corner next to me.

The behavior of couples generally has different implications. Their choices tell me more about the relationship they have with each other than about their individual issues. Some couples will ask each other, “Where do you want to sit?” Who does the asking is my first indication of how they interact. Some do it non-verbally, but there is a clear communication going on. In other couples, one partner will make a beeline for the seat of choice, unconcerned about where the other will sit. Telling? You bet! The most common seating arrangement for couples is in the two tub chairs. They can swivel to face each other or include me as a part of an open group. It works well. A small percentage of couples sit together on the couch, but never in the corner next to me. This choice generally indicates that at least one of the partners is very dependent on the other. Underlying the struggle that brought them to marital therapy may be unspoken dependency issues. In a few instances, the choice has been a kind of mutual reaction formation: the most vitriolic, hostile partners portraying their closeness to me. And a few couples choose the tub chair across from me and the far cushion on the couch, placing them almost knee to knee, and allowing them to huddle and exclude me.

Often, these are couples in which only one spouse has wanted to be in marital therapy. That partner will be facing me head one, while the other is in that distant seat.

Patients reveal many things about themselves with their non-verbal behaviors, including how they use tissues and how they choose their seats. It is our responsibility, as practitioners, to be alert to them and include them in our understanding of the patient’s needs, dynamics, and pathology.