"The Couch" is about the lives of Adam (baritone), a lawyer who dreams of becoming a chef, and Eve (soprano), who lives in the same building as Adam. Every Thursday, Eve sees Mr. Tealeaves (tenor), an unscrupulous psychotherapist. Except for a prologue, the first half (score completed) depicts interactions between these three characters. In the second half (no music written), two more characters, Ms. Football (contralto), a relationship (marriage) counselor, and Dr. Novocain (bass), a psychiatrist, become involved in the couple's lives.

The opera opens with a prologue in which the three "Psychoterrorists" sing about their belief in Freud; this is counterpointed to Adam and Eve, alone but with similar needs and questions about their lives. Thus, early on, the three Psychoterrorists are linked as a group and set in opposition to Adam and Eve.

In the opening scenes, Eve is shown being tricked into sleeping through a session with Mr. Tealeaves. After the session, she sings of her dream, which depicts her parents and an early encounter with Adam. The dream upsets her, and Adam comforts her as they ride together in the elevator of their building.

In the following scenes, Eve is shown at another session with Mr. Tealeaves, excitingly speaking about Adam. Mr. Tealeaves tries to quash her enthusiasm, calling passion "unhealthy." In the following scene, Adam is shown on the phone at work, frustrated and frenzied. His feelings for Eve are revealed when she calls at the end of the scene.

In the next scene, Eve is shown telling Mr. Tealeaves about an argument she has had with Adam, which leads to the breaking of a compromise. In the last scene of the first half (completed), Adam confronts Mr. Tealeaves for the first time. Mr. Tealeaves suggests joint counseling.

The second half (no music written) opens after some passage of time at the offices of Ms. Football. The joint sessions with Mr. Tealeaves have only intensified the confrontational nature of Adam and Eve's relationship, and Adam has refused to see Mr. Tealeaves any more. Unwisely, they seek further "therapy" with Ms. Football, who suggests they take a vacation. In the next scene, Eve discusses this with her friends on the phone, depicted by the Psychoterrorists trio. They are no help.

Adam and Eve take the vacation, at Eve's parents' summer home. Away from it all, they recover and restate their love. But fate intervenes - Adam's boss dies and he must rush back to work. Eve is left at her parents' place and panics over old memories. Meanwhile, Adam can't handle the mess at work. They are both referred to Dr. Novocain.

Dr. Novocain, in a vaudeville/musical theatre style, sings of his wonder drugs. Eve arrives, and he convinces her that he has the solution to her needs. Adam arrives and realizes what has led them astray. They are joined by Mr. Tealeaves and Ms. Football in a quintet finale in which, against the advice of the Psychoterrorists, they decide to stay together. As a dramatic catharsis, they start making love on the symbolic Psychoterrorist couch as the three Psychoterrorists commit suicide.

In an epilogue, the audience is presented with a moral imperative: "Walk out on your Psychoterrorist and don't look back!"