Dreams: theory and clinical practice- Part 1

A famous psychoanalyst Charles Brenner once said on presenting a paper: “Tell them what you are going to tell them, tell them and then tell them what you told them.” I think I will leave off the last part but, given the depth of this four-part series on working with dreams, it would be best to highlight the ground covered.

The key points covered in this the series…

• Dream interpretation is the creation of Sigmund Freud and remains the Royal Road to an appreciation of unconscious mentation in man.
• Knowing how to work with a patient’s dream is, in my view, tantamount to knowing how to do good psychodynamic work.
• As a clinician, I appreciate dreams for their vibrant portrayal of inner conflict and utilize them to facilitate the emergence of such conflict in the therapeutic field.
• Working with dreams, as I view it, is akin to learning a foreign language; while anxiety-provoking, even for analytic candidates, it can be mastered and the benefits for the treatment are bountiful.
• I intend in this overview to sketch out some of the “grammar and syntax” of dreams so that you can begin immediately to use dreams effectively in your work with your patients.
  
  

Part One: Why dreams?

In the interest of self-disclosure, I am trained as a psychiatrist, but my clinical focus for the past thirty years has been as a practicing psychoanalyst. Throughout that long stretch of time I have had a special interest in dreams, and I have taught the course on dreams and their use in clinical practice at two different psychoanalytic institutes in New York.

We know that the therapy field is awash in divergent theories and techniques of treatment and the psychoanalytic or dynamic approach is only one of many currently practiced. Given the markedly divergent perspectives of our many disciplines, you, the reader, are certainly within you rights to question how and why such a knowledge could be useful to you in your own work.

As therapists, we are all engaged in making sense of our patients’ difficulties. We design theories to explain why mental problems arise, why they persist and use our understanding of their nature to try to help. Many, perhaps the majority, of our therapies have been demonstrated to offer reliable short and often moderate term improvement in our patients’ lives and this is indeed a very significant accomplishment. However, it has been my conclusion over many years, that our capacity to induce lasting change in our patients’ lives, in their outward behavior but even more, in their self-regard and capacity to love another, can be quite a difficult matter to achieve.

In my view, the achievement of lasting change, demands the patient’s experience of our deep emotional penetration of their world.

In other words, enduring therapeutic change is dependent on our patient’s direct “here and now” awareness of our caring for him and our appreciation of his unique mind.

It is my contention that the communication of a profound understanding of your patient’s core concerns bolsters, if not in actuality creates, the shared mental space through which I believe he grows independent of theory or therapeutic technique employed.

In that regard, a person’s dream life uniquely reflects just those core personal wishes, fears and fantasies and an ability to work with them brings us immediately into intimate contact with our patient’s inner world.

Later in this series, I offer some ideas as to why such “emotional interpenetration,” if I may borrow Steve Ellman’s term, is so central to mutagenesis and lasting emotional growth.

Throughout history, humans have always maintained an intuitive sense that their dreams are meaningful. You will recall from the Bible how Joseph used Pharoah’s dream of the fat and lean kine and corn to foretell the future. They have been deemed significant even as ideas about their purpose has varied widely: from messages of a god or gods, to conviction of impending illness, death or life success. Ironically, often precisely because their meaning is internally registered as too revealing or disturbing, dreams are frequently dismissed by the dreamer as a mere consequence of fever or dyspepsia.

Nevertheless, the dream is universally counted as an extraordinary mental experience. A dream can feel alternatively thrilling or mundane, vibrant or vague, perhaps absurd or even uncanny or other-worldly, but if it is remembered, it will tug at the dreamer’s mind with a special pull. And the reason for this is simple: the dream is an experience that is recognized by the dreamer as uniquely his own. Whether he wishes or no, no matter how unpleasant the experience, every dreamer is the screenwriter, producer and director of his or her own dream. To quote Thomas Ogden: “While dreaming, we are intuiting an element of our unconscious emotional lives, are at one with it in a way that differs from any other experience.”

This fact constitutes the first and often most powerful intervention a therapist can make upon hearing any dream, that is, asking your patient “So why ... this?”

I recently began treatment with a man who had been arrested for beating his wife. He dreamt that he was placed in handcuffs but was able to slip out of them and yelled to someone nearby “Don’t you ever dare to put these on me again!” This patient had already been arrested, put in handcuffs and released by the police so that putting himself back in handcuffs was, in effect, his acknowledgment of secret guilt for a variety of sins. The dream message was: “I am a bad man and I deserve to be arrested.” Consistent with the ambivalence of mental life, the dream equally contains the self-reassuring fantasy that, no matter the circumstances, he will be able “slip out of trouble” and escape all manner of problems.

In addition to a representation of these opposing trends, in recounting the dream to me, the dream additionally contained the fantasy that I, as his analyst, would help him regain control by putting him “in irons” while equally daring me to do so.

Once patients realize that we, as therapists, are open to hearing their dreams and regard them as meaningful mental acts, most are willing to recount them no matter how confused or irrational their content. To reiterate: this brief review is intended to clarify the role of dreams in the mind, to increase your appetite for them, to bolster your confidence in making sense of reported dream images, and perhaps most importantly, to help you feel able, via an exploration of specific dream elements, to begin a conversation with your patient about their remarkable polyvalent emotional significance.

All well and good I can hear the reader intone, but what is to be done when, as often is the case, the dream is so irrational as to not make sense?

I want to emphasize that the core therapeutic value of working with a reported dream is independent of determining its meaning; in other words, the inquiry process is more precious than whatever specific information can be derived. There are two important reasons for this:

Immediate cathartic relief in the sharing, particularly in the case of a painful or anxiety-laden dream.

The longer-term creation of a “therapeutic space” within which the two of you work and come to understand each other.

I want to stress this second less visible extended benefit that devolves from your effort to understand this most intimate of mental productions. The retelling of a dream is experienced much like the effect of the confessional in religious practices; in other words, the recounting of a dream satisfies a deep desire in which exists in all of us to share our struggle with a caring other who can potentially offer comfort, interest, reprieve, hope.

Even if you have absolutely no clue, as often may happen when first you hear a dream and have no idea what to say or focus on, which I would hope would not be the case following reading this, your very willingness to inquire into and to receive these often seemingly “crazy” emotion-laden communications will enormously enhance both your authority and your therapeutic alliance with your patient.

Your engagement with your patient’s dream, to borrow yet a third metaphor, much like a parent’s absorption in his child’s fantasies and stories, is internally registered by the patient as a strong sign of your empathy and care. Furthermore, your willingness to accept material that feels irrational or “nutty” to your patient, helps indirectly to promote greater courage in him to know himself and to share himself with you.

The patient who feels our interest as genuine, the patient who “trusts”, the patient who sees first hand our effort to know him as it were ‘through his skin,” in short, the patient who experiences our effort to understand is far more apt, in my experience, to ally with our more hopeful aspirations for him and seriously commit himself to change his attitude or approach in life.

Douglas J. Van der Heide, M.D. is a training and supervising psychoanalyst at the Psychoanalytic Association of New York affiliated with New York University Medical Center and a member of the New York Psychoanalytic Institute

Navigation Menu

Part One: Why dreams?

Part Two: A brief history of dreams in EARLY psychoanalytic thinking.

Part Three: Important shifts in the psychoanalytic understanding of the nature of dreams and “dream-thoughts.”

Part Four: How a composite understanding of dreams can be used by therapists in their daily work.

Photo by Jr Korpa on Unsplash