Dreams present us with a unique therapeutic opportunity. This presentation will examine how adequately we are prepared to take advantage of this opportunity and will offer an approach designed to meet what I feel are the shortcomings in the way we have gone about such preparation.

Rarely is dream work offered in any serious fashion to medical students. Working with medical students in their clerkship years it has been my experience, using the process I will describe, that they can learn enough about dream work to catch a glimpse of the self-healing potential of dream imagery. With it comes the realization that self-healing occurs in the emotional as well as in the physical realm.

In the course of our speciality training we learn about dreams in a variety of ways. At the level of residency training there are a number of opportunities for exposure to dreams in their significance for therapy. Residents may be encouraged to include Freud’s classic volume in their reading. From their clinical presentations they may begin to get some idea about how dreams in their supervisory experience is contingent on the interest and enthusiasm of the supervisor for dream work. For those who are concurrently in therapy, work on their own dreams may prove to be an enlightening experience but one that does not actively or effectively orient them to doing dream work with others. What is lacking is a systematic approach to teaching dream work that offers the neophyte a "hands-on" approach. The message that gets across to residents is: If you are seriously interested in dream work go in for psychoanalytic training.

While it is true that psychoanalytic training should give a deeper grasp of dreams and their clinical significance it, too, is subject to the same piecemeal approach. Candidates emerge with considerable theoretical knowledge based on what Freud, Jung and others have written about dreams but still hold the subject in great awe and are quite insecure in dealing with their patients’ dreams. Being so inbued with theory, their knowledge often operates to their disadvantage. Lacking a technique that would offset this insecurity, they often interpose theory between the dreamer and themselves. No theory can replace the task of eliciting the necessary data. It is this task which has not received enough attention. While theory is important as a guide in psychotherapy, it is never a substitute for data.

In the clinical conferences devoted to dreams the candidate brings in the dream of a patient, what went on in the hour the dream was presented and a brief outline of the course of therapy. The conference is devoted to exposing as much as possible about how the dream contributes to the understanding of the patient’s dynamics and the nature of the transference. This was all very well as far as it went but it didn’t go far enough. It was not dream work if that term means the clarification of the experiential reference of every image of the dream. More to the point, it was using the dream to understand and further the therapeutic line. Very often the limitations of time alone would result in "headline" interpretation, the emphasis being on one or more powerful metaphorical images to impact the patient. Although time is a problem in the structured therapeutic session the real problem in the seminar was that we were working with a "dead" dream. We did not have a live dreamer in the room, one with whom we could interact and where an active approach to eliciting essential data could be demonstrated. What the candidate brought to dream work was the patient’s spontaneous associations. While necessary they were not sufficient.

My point is that nowhere along the line, even in the most intensive training, is the therapist offered what might be regarded as a practical and workable approach to dreams, one that demystifies dream work and provides the structure needed to help a dreamer uncover the connections between imagery and waking life experience. This is not to say that dream work can be made easy or that the mystery of our nocturnal visions disappears completely but, rather, that the patient can be approached with a more realistic assessment of the task to be accomplished.

These considerations led me to seek another way to teach dream work. The opportunity arose in 1974 when I was invited to teach a group of young therapists in Sweden. Having decided to teach dreams experientially, the problem I faced was how to structure an educational rather that a clinical approach. This meant establishing a very different contract between the dreamer and the group and between them both and myself. I was not there as a therapist but as a teacher. The dreamer was not there as a patient but as a student open to learn about dreams to the extent that his/her curiosity and desire to learn made it possible. The members of the group were there not to work on their own internal processes but were to be helpers to the dreamer to the extent the dreamer wanted their help. There was no hidden agenda where I as therapist would operate from a body of specialized knowledge and technique not privy to the dreamer. In other words, no formal therapeutic techniques were used. Neither I nor the group members were going to deal with defenses, analyze resistance or expose transferences.

To meet this objective the process had to be structured to meet two basic needs of the dreamer. The first was to feel safe in sharing a dream. I refer to that as the safety factor. The second was to devise a series of strategies that would help the dreamer make discoveries about the dream that were difficult to make alone and to do it in a way that would never go beyond the limits set by the dreamer. I refer to that as the discovery factor.

Certain general guidelines were set down to insure the dreamer’s safety. It was important to emphasize the private and intimate nature of the dream so that no one felt compelled to share a dream unless there was a positive desire to do so. Secondly, at any point in the process where a response was called for the dreamer could go to any level of sharing that felt comfortable. The dreamer was responsible for setting his/her own limits. No one would push the dreamer beyond those limits. Finally, the control of the process from start to finish rested in the dreamer’s hands. He/she could stop the process at any point. In addition it was made clear that the work that went on in the course was of a confidential nature. With all these safeguards in place it was my hope that dream sharing would take place and that trust in the process would be generated.

The group’s task was to help the dreamer. The various strategies to be used had to be consistent with the dreamer’s need for safety and control of the process. The success of the work hinged directly on maintaining the dreamer’s trust and confidence in the process.

The question that had to be put to the test was whether or not the natural curiosity we all have about dreams and the impulse to learn about the therapeutic value of dreams would offset any anxiety about exposing oneself before one’s peers and any concern the impact of the work would have on their personal therapy. These anxieties, while manifest initially, gradually eased as the students came to trust the process and began to feel secure in the fact that they were not being approached as patients in treatment. It became clear to them that I was there in the role of teacher, not therapist and that my only special responsibility was to see that the safety of the dreamer was assured and that the group learn how to work with the process. In all other respects I participated in the process in the same way as did other members of the group. I had the same option to share a dream and did so on occasion. It not only did not threaten the work they were doing in their own therapy but had the effect of enhancing and complementing that work.

THE PROCESS

The process begins with someone volunteering to share a dream. Only the manifest content is shared. No associations or ideas about meaning are given at this point. If characters appear in the dream the dreamer indicates whether or not they are real persons and, if so, what the relationship is to the dreamer (friend, relative, etc.). Occasionally the simple act of telling the dream aloud to the group results in a sudden insight. The act of volunteering implies some readiness to lower one’s defensive structure and this, in turn, results in seeing more.

The strategies that then follow are all designed to help the dreamer get in touch with the data that shaped the dream. These strategies are not automatically invoked but unfold at the behest of the dreamer. In the first of these the group makes the dream its own and attempts to do two things with it. They share with each other the feelings they associate to the imagery of the dream and then go on to explore the metaphorical possibilities of each image. It is understood that whatever is said is their own projection into the dream. At this point they are neither looking at nor talking to the dreamer. The dreamer listens without actively participating and is free to accept or reject anything coming from the group. The point of the exercise is to help the dreamer begin to move closer into the dream under circumstances where it feels safe to do so.

This opening strategy which, on the face of it, seems quite random is, in fact, very powerful. Aside from the fact that the group may some up with a feeling or give a meaning to an image that feels right on target for the dreamer, there are a number of other features that operate more subtly to further the dreamer’s grasp of the dream. After going public with the dream there is the reassurance that others are taking the dream seriously, are applying it to their own lives and coming up with meaningful connections to it out of their own experience. By sharing their projections with the dreamer they are sharing a bit of their psyche with the dream just as the dreamer shared a bit of his/her psyche with the group.

At the end of this exercise the dreamer is invited to respond. He/she is free to shape the response in any way he/she chooses. This is the dreamer’s opportunity to offer associations and ideas about the dream’s meaning as well as the impact of the group’s work. There is the freedom to go to whatever level of sharing feels comfortable, with the assurance that no one will exert any pressure to go beyond that level.

In this initial strategy the group’s work will occasionally have helped the dreamer clarify the dream to the point where he/she feels satisfied and decides to stop. Further work, however, is generally necessary providing the dreamer wishes to go on. The next strategy involves a dialogue between the dreamer and the group designed to clarify the source of the recent emotional residues that triggered the dream. It consists of direct questions designed to help the dreamer explore the emotional context of his/her life during the period immediately preceding the dream. There are questions like:

Can you recall what feelings the day left you with?

Can you recall what thoughts or feelings you had on falling asleep?

Did anything else happen in the recent period before the dream that left you with any particular tensions or feelings?

The dreamer is instructed to consider these questions as instruments to use in exploring his/her psyche. They are not questions that demand an answer. The dreamer has the freedom to respond or not. If working with the question is productive it is the dreamer’s decision to decide how much to share with the group. As the dreamer begins to trust the process he/she soon learns that the more that is shared with the group the more help the group can be.

When this phase of the exploration is over, and should the dreamer wish to go further, the next effort at eliciting data is to read the dream back to the dreamer, one scene at a time, while inviting the dreamer to say anything more about the imagery in each scene. The dreamer now has at his/her disposal the data that came up spontaneously in the initial response plus any additional data the group elicited about significant recent events and feelings. Having more data on hand, and given the opportunity to play back the imagery against all that has come out so far, the dreamer is often able to add further associations. There is another more subtle factor that tends to increase the yield. When someone other than the dreamer reads back a scene it evokes a different feeling in the dreamer than when the dreamer plays with it privately. What may have been seen as a somewhat ephemeral creation comes back as a more real, more palpable, and now a more public creation. More of the dreamer’s psyche is stimulated by experiencing it in this objectified way.

When done skillfully the playback often brings the dreamer to the point of closure. When this does not happen there is a final strategy which the dreamer may invoke, namely, an invitation to the group to offer what I refer to as integrating or orchestrating projections. The preceding two strategies had as their goal eliciting the information needed to bridge the gap between dream image and waking reality. As more information comes to light there is more of a chance that connections will occur to the dreamer. There are situations, however, where the information has surfaced but has not come together in a way that is sufficiently helpful to the dreamer. The final group strategy addresses this. If anyone in the group now sees a connection between what the dreamer has said and its metaphorical connection to one or more images in the dream or to the whole dream itself that the dreamer has not seen, it can now be offered to the dreamer as an orchestrating or integrating projection, orchestrating because the group member tries to bring the diverse elements together and a projection because it is the group member who makes the selection and fits it to the imagery. It may just be his/her projection or it may be validated by the dreamer, in which case it can be very helpful.

There follows a final stage to the process, one that no longer involves the group. After a dreamer has presented a dream, and sometime before the next meeting, the dreamer is encouraged to take a second look at the dream. Being alone and not under group pressure a dreamer may sometimes see connections that were not apparent during the group session. At the next meeting the dreamer is invited to share any additional thoughts.

SKILLS

There are skills involved in dream work. They can be conceptualized and taught but they require practice. The two basic skills are the art of listening and the art of putting questions to the dreamer that help elicit relevant information.

Listening is a complex skill which requires not only listening to everything a dreamer says but also listening to the way it is said, listening to the accompanying feelings, listening to what is not said and, above all, listening without an a priori bias as to what is or is not important. What might seem at first like an incidental or trivial comment might assume importance as more information emerges, the dream comes out of the unique life history of the dreamer. The more one is in tune with that, rather then relying on foregone conclusions as to the dream’s meaning, the more likely it is that the dreamer will be helped. For the neophyte this means more listening and less temptation to yield to the impulse to superimpose a ready at hand interpretation.

The art of questioning is the art of putting questions to the dreamer that do not attempt to lead the dreamer in a particular direction, questions that do not go beyond the limits set by the dreamer and yet provide the necessary stimulus for the dreamer to come up with relevant information. It involves careful listening to the answer and the selective choice of follow-up questions. If, for example, there is an elderly woman in the dream about whom the dreamer has not offered any spontaneous associations it is appropriate in the playback part of the dialogue to confront the dreamer with the image and inquire if any thoughts come to mind as to why that image appeared that night. The dreamer might think for a moment and then say, "Oh yes, my mother called me last night." This is a factual response but since dreams come out of the feelings associated with facts and not the facts themselves a follow-up questions would be required: "Can you go back to that telephone call and say anything more about the feelings you were left with?"

A fuller presentation of the process and techniques involved appears elsewhere (1,2,3).

APPLICATION TO THERAPY

There are a number of ways this experience finds useful application to clinical practice. Perhaps the most important result is the demystification of dream work and the feeling of greater security in pursuing it. The process offers the therapist a more structured approach to the task. Taught to rely on the power of free association the therapist fails to realize that an active inquiry is necessary to evoke the relevant data. Before the dream is even told, for example, there should be clarity about when the dream occurred. This can be of help in alerting the therapist to possible contexts that may have given rise to the dream. Did the dream occur the night after the last session? The night preceding the present session? In therapy one begins with the patient’s spontaneous associations and encourages the full play of associations to all the images. This is a necessary beginning but not sufficient by itself. Direct questioning is needed to explore more fully the recent emotional context related to the occurrence of the dream at a particular time in the patient’s life. What can then prove useful is to further follow the structure of the dialogue as described in the process to the extent it seems necessary. The patient is invited to take a second look at the dream as the therapist reads it back, scene by scene, with emphasis on the specific images that still remain obscure. The patient now has his/her spontaneous associations to work with as well as whatever additional light that has been shed on the recent context.

The therapist’s interpretive base is, of course, much broader and deeper than obtains in the experiential group but, even here, the stricture holds that no interpretation should be offered until a systematic effort has been made to elicit as much of the relevant data as possible. Even then the possible projective element in any interpretation should be kept in mind. Interpretations had best be offered as what Bonime (4) refers to as interpretive hypotheses to be validated by the patient.

Both patient and therapist come to respect the amount of work necessary to get a dream to yield its secret. The therapist comes to respect the patient’s ability to make the connection between image and reality as the relevant information is helped to surface. The patient comes to realize that dream work is work that he/she has to do and that only he/she is the final arbiter as to whether or not it is done successfully. The patient experiences a sense of authority over the dream and comes to appreciate it as a powerful and available healing source.