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Psychoanalytic
and Neurobiological Perspectives
on
the Use of Dreams in Psychotherapy
John H Herman, PhD
INTRODUCTION
During the 20th Century dreams were more
rigorously scrutinized from a wider variety of perspectives than they had
been previously. At the opening of the century, Freud published what would
become perhaps its most significant book, The Interpretation of Dreams.
In it he approached dreams as the product of an active mind dealing with
the dreamer's thoughts from the preceding day, the dreamer's psychic
conflicts, and the dreamer's most disguised life-long wishes.
A century after the publication of the Interpretation
of Dreams, many of the concepts of psychodynamic theory Freud first
introduced in it stand as our contemporary model for understanding the
psyche, concepts ranging from infantile wishes and drives to defense
mechanisms and manifest vs. latent levels of meaning. Many of the precepts
he established for interpreting dreams remain at the core of all
psychodynamic or insight oriented psychotherapies.
This presentation will deal with the
Interpretation of Dreams, their neurobiology, and the use of dreams in
psychotherapy. Contemporary psychotherapy essentially consists of a
variety of techniques that have evolved from Freud's premise that through
the examination and interpretation of free associations a patient will
arrive at the repressed material that underlies neurotic symptomatology.
Dreaming is considered a particularly rich source of psychic material, as
the manifest dream is regarded as the distorted offshoots of the defended
against, unconscious, core, psychic conflicts.
In 1953, Aserinsky and Kleitman awakened
subjects from sleep when their eyes were rapidly darting back and forth,
and reported this to be the time most likely to produce vivid dream
recall. This marked the beginning of the study of the neurobiology of REM
sleep and the examination of the relation of this state of sleep to the
dreaming process. Dreaming occurred in conjunction with a biological
substrate, a unique brain state when it was most likely to occur. Sleep
was found to be divided into two forms, REM sleep and NREM sleep, each
very different from the other, and both reoccurring cyclicly throughout a
normal night of sleep.
In this presentation, I will also describe
two dreams, one from Interpretation of Dreams and one from a
current patient of mine. These dreams and their associations are examined
in detail to illustrate what may be derived from a single dream image. I
will also attempt to demonstrate how laboratory investigations of REM
sleep have provided helpful information for understanding the dreaming
process.
I apologize in advance for the fact that
this manuscript will not deal with many major areas of dream investigation
relevant to psychoanalysis, including object relations theory and Kleinian
psychoanalysis. Also, many important publications, by Freud and others,
will not be included. Neither of the two dreams described, one from Freud
and the other from a patient of mine, are unlikely to have been from REM
sleep. Both dreams consist of more or less static images without plot
development or narrative, each is more consistent with sleep onset
mentation, referred to as hypnogogic hallucinations.
I. Some major
developments in the psychoanalytic study of dreams:
1. The publication of The
Interpretation of Dreams
This section consists of a very brief
background to Freud's model of dreaming and his concept of the mental
apparatus that produced dreams. He writes, "In This House, on July
24, 1895, the Secret of Dreams was Revealed to Dr. Sigm. Freud," in
Chapter 1 of Interpretation of Dreams, clearly not an expression of
extreme timidity. The secret revealed was that "a dream is the
fulfillment of a wish". From an epistemological standpoint, the
wish-fulfillment theory proposes that the meaning of a dream might be
quite different from its manifest content, in fact the meaning might be
the opposite of the manifest content. This disparity, to Freud, implied
mechanisms of disguise and distortion underlying the construction of
dreams. The wish-fulfillment theory requires the analyst to first listen
to the patient's associations and then explore far from the dream's
manifest content. From the standpoint of technique, the disparity between
the manifest and latent content of dreams became the foundation of
psychoanalysis, in which the exploration of dreams, of forgetting, of
mistakes, of slips of the tongue, and of impulsive acts, are used to
reveal the unconscious motivations underlying the patient's conflicts and
symptoms. Interpretation of Dreams, most importantly, was the first
rigorous demonstration of unconscious determination of behavior,
significance that spreads well beyond dreams.
The mechanisms Freud describes as
disguising the meaning of a dream are representation, condensation,
displacement, symbolization, and secondary revision. The dream images, or
manifest dream, represent latent dream-thoughts that remain unconscious. A
pictorial story in a disguised fashion represents thoughts blocked from
the patient's consciousness. An image is capable of entering the dream
only if it has multiple meanings that converge on it, the principle of
condensation. Displacement is a mechanism of disguising the dream's
meaning by transferring it from its conflicted origin to a more neutral
subject. Secondary revision makes the dream more palatable to waking
thought, similar to the way we automatically attempt to make waking
experiences more coherent.
The process of dream analysis is as
follows: Free association starts from an element in the dream and
establishes mental connections between waking events and the dream, which
allows the reconstruction of the latent dream-thought. Each dream is the
veiled expression a latent dream thought and an underlying unconscious
infantile wish.
Reading the formulistic dream
interpretations given by some Freudian analysts to patient's who suffered
trauma, I have reservations about too rigid adherence to the Freud's
wish-fulfillment theory, as opposed to Freud's technique of exploration of
free associations. With respect to Freud's wish-fulfillment theory, Owen
Renik states, "when a traumatic event is replicated accurately in the
manifest content of a posttraumatic dream, it can be assumed that the
actual outcome of the traumatic event has been reassuring as compared with
the dreamer's unconscious punishment fantasies. (Psychoanalytic
Quarterly,
1981, 50, 159-189)."
Renik describes the case of a young woman
who was forced into an alley by a couple who robbed her, forced her to
strip, stole her clothes, and threatened her with a knife. She suffered a
traumatic neurosis. In her psychotherapy, she reported dreams which
precisely replicated the robbery. Renik interpreted fulfillment of her
Oedipal wishes, the patient's guilt, and her feeling of deserving
punishment (ibid.). Then he comments, "This was not a treatment that
developed into a psychoanalysis."
When one critiques Freudian dream theory,
it is critical to separate his wish-fulfillment explanation of the meaning
of dreams from his psychoanalytic model of inquiry. His monumental work
gave birth to a theory of dream meaning and a technique of gathering free
associations. It appears as if the latter has remained of greater clinical
significance than the former.
II. Freud's dream of the
botanical monograph:
In this section I describe one dream and
its associations in detail to provide a model of how dream interpretation
can operate under the best of conditions, i.e., when resistance is not a
factor, or is a minimal factor. This will hopefully illustrate some
benefits of dream interpretation. The specimen dream that I employ to
illustrate Freud's technique is his botanical monograph dream, which he
dreamt in March, 1898. It is repeated in its entirety twice in Interpretation of Dreams. I selected it because the dream
material is extremely sparse, material that would be opaque without
Freud's technique. The profusion of consequential associations he
assembles from this dream fragment stands as a model for deriving crucial
material from a seemingly uninterpretable dream image.
"I had written a monograph on a
certain plant. The book lay before me and I was at the moment turning over
a folded colored plate. Bound up in each copy there was a dried specimen
of the plant, as though it had been taken from a herbarium (Ibid.,
p169)."
No action, no characters, and no narrative
are present, this is a sparse starting point indeed.
Freud's associations to the dream begin as
follows: The morning of the dream-day he saw a new book on the genus
cyclamen in the window of a book shop. Cyclamens are small plants with a
cluster of thin, tender shoots each supporting little, delicate,
purplish-pink flowers with their translucent petals drooping down.
Cyclamens were his wife's favorite flowers. Freud reproached himself for
rarely remembering to bring her flowers. The recollection of the book and
his self-criticism are the event (and thought) from the dream-day that
Freud believed to trigger the dream.
Freud continues: He remembers an anecdote
he recently told a group of friends, which he used as evidence that
forgetting is determined by an unconscious purpose (p169).
The anecdote:
"A young woman was accustomed to
receiving a bouquet of flowers from her husband on her birthday. One year
this token of his affection failed to appear, and she burst into tears.
Her husband came in and had no idea why she was crying till she told him
that today was her birthday. He clasped his hand to his head and
exclaimed: "I'm so sorry, but I'd quite forgotten. I'll go out at
once and fetch your flowers". But she was not to be consoled; for she
recognized that her husband's forgetfulness was a proof that she no longer
had the same place in his thoughts as she had formerly."
Freud remembers that the woman in this
anecdote had encountered his wife two days before the dream, told her that
she was feeling quite well, and inquired after Freud, her former therapist
(pp. 169-170). (One wonders what Mrs. Freud thought of running into her
husband's patients, or what Freud thought of his wife giving him messages
from patients.)
Alexander Grinstein (Sigmund Freud's
Dreams, 1980, International Universities Press, New York) notes that Freud
rarely remembered to buy his wife flowers, but "he regularly
remembered to do this for his mother (p49)". Grinstein's observation,
if true, introduces an Oedipal element to the dream.
Returning to Freud's associations: The
botanical monograph in the dream reminds him of the monograph he wrote on
the coca plant four years earlier which had interested an associate, Dr.
Carl Koller, in cocaine's anesthetic properties. Koller was present when
Freud told the above anecdote. Freud proposes in The Interpretation of
Dreams that it was he who introduced cocaine's anesthetic properties to
Koller, with whom he discussed his idea, who then performed the first
experiments and published results demonstrating cocaine's use as an
anesthetic. Freud criticizes himself for not having been more thorough and
performing the experiments himself. His self criticism had been
intensified a few days before the dream when he thumbed through a copy of
a festschrift to Koller in which his discovery of cocaine's anesthetic
properties was saluted.
This led Freud to the memory of a
conversation with another colleague, Dr. Leopold Konigstein, the previous
evening concerning the awkwardness of medical treatment among colleagues.
Freud was at this time jokingly criticized by friends for being too much
absorbed in his "favorite hobbies", probably referring to his
continual speculations about unconscious determinants of behavior. Freud
then remembered that while talking, they were joined by another professor
and his wife, who Freud congratulated on their "blooming" looks,
another floral reference. The connection then registered to Freud between
the lady whose husband forgot flowers, his wife's favorite flowers, and
the botanical subject matter of the dream.
In 1895, shortly after Carl Koller's
discovery of cocaine's anesthetic properties, Freud's father suffered an
attack of glaucoma. It was diagnosed by Dr. Koller only after Freud
dismissed his father's symptoms as inconsequential. The same Leopold
Konigstein, mentioned above, was the ophthalmological surgeon who operated
on Freud's father, and Koller was the anesthesiologist who administered
the cocaine anesthetic. Freud had mentioned cocaine's anesthetic
properties in his monograph, previously assisted Konigstein in its use in
surgery on a dog's eye, discussed it as an anesthetic for human surgery
with both Konigstein and Koller, but Freud had not written what were to
become the landmark manuscripts demonstrating its use in ophthalmological
surgery . Koller had published the key anesthetic paper, Konigstein had
published the seminal ophthalmology paper while Freud's manuscript on
dreams lay unfinished on his writing table.
In what I find to be one of the more
touching sentences written by Freud, in his preface to the second edition
of Interpretation of Dreams he writes in the summer of 1908:
"For this book has a further
subjective significance for me personally- a significance which I only
grasped after I had completed it. It was, I found, a portion of my own
self-analysis, my reaction to my father's death- that is to say, to the
most important event, the most poignant loss, of a man's life." His
father died in October, 1896, 17 months before the botanical monograph
dream.
Freud's associations to the monograph dream
continue:
"If ever I got glaucoma, I should
travel to Berlin and get myself operated on, incognito, in my friend's
house (Fleiss), by a surgeon recommended by him. The operating surgeon,
who would have no idea of my identity, would boast once again of how
easily such operations could be performed since the introduction of
cocaine; and I should not give the slightest hint that I myself had had a
share in the discovery."
He next associated to the "dried
specimen of plant" in the dream and recollected his failure in high
school to identify a drawing of a plant during a preliminary botany exam.
This reminded him of a related plant, the compositae, members of which
include sunflowers, lettuce, and his favorite, the artichoke. Freud
relates, "Being more generous than I am, my wife often brought me
back these favorite flowers from the market." (Interpretation of
Dreams, p171).
Returning to his associations, Freud
relates the monograph dream to a letter he received from his friend Fleiss
the day before in which Fleiss said,
"I am very much occupied with your
dream-book. I see it lying finished before me and I see myself turning
over its pages (Ibid., p171)." Freud comments, "How much I
envied him his gift as a seer! If only I could have seen it lying finished
before me (Ibid., p172)."
Freud then recollects his fondness for
collecting colored monographs when in medical school. What follows is a
remarkable early childhood memory:
"It had once amused my father to hand
over a book with colored plates (an account of a journey through Persia)
for me and my eldest sister (Anna) to destroy. Not easy to justify from
the educational point of view! I had been five years old at the time and
my sister not yet three; and the picture of the two of us blissfully
pulling the book to pieces (leaf by leaf, like an artichoke, I found
myself saying)… (Ibid., p172-3)."
Freud connects the above to his
"favorite hobby" in medical school, collecting and owning books.
He states, "I had recognized that the childhood scene was a 'screen
memory' for my later bibliophile propensities (Ibid., p173)." The
Persian book memory reminded Freud of "running up a largish account
at the booksellers" which he was not able to pay, which reminded him
of the discussion the night before with Konigstein about being too much
absorbed in favorite hobbies.
These associations then lead Freud to the
meaning of the dream:
"All the trains of thought starting
from the dream- the thoughts about my wife's and my own favorite flowers,
about cocaine, about the awkwardness of medical treatment among
colleagues, about my preference for studying monographs and about my
neglect of certain branches of science such as botany- all of these trains
of thought, when they were further pursued, led ultimately to one or other
of the many ramifications of my conversation with Dr. Konigstein. …The
dream turns out to have been in the nature of a self-justification, a plea
on behalf of my own rights. …Even the apparently indifferent form in
which the dream was couched turns out to have had significance. What it
meant was: 'After all, I'm the man who wrote the valuable and memorable
paper (on cocaine)', …'I am the conscientious and hard-working student.'
… what I was insisting was: 'I may allow myself to do this.' (Ibid.,
p173)."
Given the self-critical, nagging nature of
Freud's associations, one might disagree with his assertion that the
dream's meaning was the fulfillment of a wish. He is critical of himself
for not buying flowers, for not diagnosing his father's glaucoma, for not
performing the studies and publishing further on cocaine, for not having
completed his dream manuscript, for having spent too much money on books;
virtually every association is critical. The botanical monograph dream, he
maintains …"turns out to have been …a plea on behalf of my own
rights." This is more an adult bargaining with a punitive super ego
than infantile wish-fulfillment.
The collection of associations to the dream
of the botanical monograph appears of far greater psychic import in
Freud's self analysis than the wish-fulfillment meaning he assigns it. It
appears that the real work of Freud's self analysis in his examination of
this dream resides in his painstaking construction of a network of
associations dealing with current and past thoughts, conflicts and wishes.
His memories of forgetting his wife's favorite flowers, misdiagnosing his
beloved father's glaucoma, of not publishing further on cocaine are
poignant and moving, his wish-fulfillment interpretation is empty by
comparison.
Today one would not interpret
wish-fulfillment with respect to the botanical monograph dream, or at best
it would be a minor aspect of the interpretation. One would surely address
Freud's constant self criticism. Depending on the transference and the
stage of therapy, one might interpret the narcissistic grandiosity in his
assumed entitlement to publish the experimental cocaine papers. One might
interpret Freud's conflicted feelings about the death of his father and
his wish to have taken better care of him. One might wonder aloud about
the meaning of destroying his father's travel book. Could this have been
repressed Oedipal material? Also, forgetting his wife's flowers when his
wife remembered flowers for him, considering Freud's pride in his memory,
what could this mean? In short, the contemporary analysis of Freud's
botanical monograph dream would deal with his conflicts, defenses, and
personality structure.
III. Rules from Freud
for dream interpretation
In this section I briefly review some of
Freud's technical recommendations for dream interpretation for the purpose
of describing his technique which we may then contrast to more
contemporary techniques. In "The employment of dream-interpretation
in psychoanalysis," 1912, (in Freud: Therapy and Technique, Collier
Books, New York, 1963) Freud proposed rules for dream interpretation
1. Dream production can serve the purpose
of a resistance. If so, analyzing resistance always takes precedence over
dream interpretation.
2. In general, do not continue the dream
interpretation into subsequent sessions. Free association always takes
precedence, including "fresh" dreams.
3. The more psychopathology the patient
displays, the less likely it is that their dreams will be capable of
complete interpretation.
4. The following comment is almost
identical to what I will describe from Milton Kramer's research on dreams
from laboratory awakenings: "…several dreams occurring on the same
night are generally nothing more than attempts, expressed in various
forms, to represent one meaning." (p100, Freud: Therapy and
Technique, Collier Books, New York, 1963)
In "Remarks upon the theory and
practice of dream-interpretation" (1923), (in Freud: Therapy and
Technique, Collier Books, New York, 1963), Freud adds several techniques
for dream interpretation:
1. Proceed chronologically directing the
dreamer to associate to the "elements" of the dream in the order
in which they occurred in the dream's description. He considers this the
classical and best technique.
2. A second technique: Select a particular
element of the dream because of its special characteristics, such as that
which is the most striking, or shows the greatest clarity or sensory
intensity, or some spoken words in the dream.
3. A third technique: Disregard the
description of the dream and ask the dreamer for associations from the
events of the preceding day.
4. Give no instructions if the dreamer is
familiar with dream interpretation technique, allowing him or her to
select with which associations to begin.
Then Freud states that "what is of far
greater importance is the question of whether the work of interpretation
proceeds under a pressure of resistance…" He asserts that the
majority of dreams in a difficult analysis do not offer much prospect of
collaborating with the dreamer, and that one can not learn anything of the
question of where the dream's wish-fulfillment may be hidden. But, if the
patient's resistance is low,
5. During a successful interpretation, the
dreamer's associations will first diverge, touching upon a great number of
associations and ideas, and then converge on to the dream thoughts the
analyst is looking for.
This is a comment I have found most
helpful. It accurately describes the process during interpretation of
listening without comment to the patient's many associations, followed by
a process of the patient and/or the therapist tying the associations to
contemporary conflicts and symptoms. Perhaps Freud's wish-fulfillment
theory of dreams was a defense against addressing his current conflicts
and symptoms. Perhaps he was not ready to address the narcissism that is
so evident, along with unparalleled brilliance, in Interpretation of
Dreams.
6. "It is only too easy to forget that
a dream is as a rule merely a thought like any other, made possible by an
easing up of censorship and by unconscious intensification, and distorted
by the operation of the censorship and by unconscious elaboration.
Finally, in this publication Freud quips,
"It is a good thing to bear in mind the fact that people were in the
habit of dreaming before there was such a thing as psychoanalysis."
IV. A contemporary
perspective on dream interpretation
In this section I have selected the Steven
Levy's interpretive technique because of its simplicity and atheoretical
nature. In Steven Levy's Principles of Interpretation (Jason Aronson, Inc,
Northvale, New Jersey, 1990), he maintains that most patients believe that
dreams are related to some "hidden" aspect of themselves, but
might have differing understandings of the concept "hidden".
Patients also believe that the therapist will be able to discern this
hidden meaning. "Thus when a patient introduces dream material, the
therapist must recognize that the patient is taking a risk, which although
it may be based upon certain distorted and unnecessary fears, nonetheless
indicates a degree of trust and willingness to explore new material. (p44)
Levy warns that failure to respond to the patient's dream report
"gives the patient a powerful indirect message about avoidance or
unacceptability of unconscious material". (p45)
Levy's method includes the following:
1. Refer to dreams in the initial
instructions to the patient, specifically when instructing the patient to
mention whatever comes to mind. He instructs the therapist to state some
version of the following to the patient following the first dream report:
"The dream, as you remember it, can be
thought of as a reflection of certain thoughts, feelings, wishes, and
fantasies in you, perhaps stirred up by recent experiences of yours, which
are represented in the dream in ways that make them either more acceptable
to you or so disguised that they are at first unrecognizable. We can learn
a great deal about you by understanding what these hidden trends are, as
well as by seeing how and why you disguise them." (p47)
The above statement addresses the manifest
and latent content, day residue, dream work, and "makes the patient a
collaborator in the effort, often thereby reducing the patient's anxiety
about reporting dreams. Levy's words of instruction are well selected to
lay the groundwork for future dream analysis.
2. The patient should not be directed to
discover the meaning of a dream, instead the dream should be regarded as a
starting point for the patient's free associations. Do not attempt to
construct a coherent "meaning" of the entire dream.
"Whenever possible, the patient's own
ideas should be sought so that he becomes familiar with unconscious
mechanisms that are sometimes most clearly seen in dream material."
(p48)
3. Levy advises the therapist to ask a
question such as "When you think about the dream, what thoughts and
feelings come to mind?" (p46) or the therapist might mention an
element of the dream and ask the same question.
4. Levy strongly recommends integrating
observations and/or inferences drawn from other sources with the dream or
its associations. For instance,
"the frightening cruelty in your dream
, when compared to the way we have seen how you are overly fair in your
evaluations of your employees, gives us a hint about why your are so
careful when you are making judgments about people. At some level, you
must recognize and worry about this trend toward cruelty in yourself and
must always be on guard against it." (p46-47)
5. An object of dream interpretation is to
help the patient to see his dreams as a reflection of many different
trends within himself, some more ego syntonic than others.
6. When the patient introduces a dream with
a preamble of any type, it should be thought of as part of the dream
material. For example, patients might introduce a dream by describing it
as merely a fragment or insignificant, which might indicate its
exceptional significance. He advises asking the patient for associations
to the preamble.
Levy is one of the therapists who I would
like to have been my analyst. He seems compassionate, insightful, and
respectful of his patients.
V. Is the dream, and
specifically its latent content, as significant as Freud maintained?:
In this section I will review some
post-Freudian publications that have questioned the relevance of the
so-called latent dream and the relevance of dreams per se to
psychotherapy. The intent of this section is to highlight some of the
controversies within Freudian psychoanalysis related to dreams. In 1954
Erik Erikson observed that "unofficially" psychoanalysts make
use of the manifest dream. An American Psychoanalytic Association panel
report concluded that "on the basis of the panelists' presentations
we must award the manifest dream a favored, but not unique place in
clinical work…" (Pulver, S and Renik, I, "The clinical use of
the manifest dream, J of the Am Psychoan Ass, 32, p161, 1984).
In 1967 The New York Psychoanalytic
Institute published a monograph titled "Indications for
Psychoanalysis: The Place of the Dream in Clinical Psychoanalysis".
It was the result of a two year study of dreams by the Kris Study Group
under the Chairmanship of Charles Brenner. The Kris report concluded that
(1) the dream is, clinically speaking, a communication in the course of
analysis similar to all others;
(2) it does not provide access to material otherwise unavailable;
(3) it is simply one of many types of material useful for analytic
inquiry;
(4) it is not particularly useful for the recovery of repressed childhood
memories;
(5) Freud's theory that the dream work is governed by the interplay
between the primary process and the secondary process is not compatible
with the structural theory and ought to be discarded.
In 1970 Ralph Greenson, (The exceptional
position of the dream in psychoanalytic practice, Psychoan Quart, 1970,
39, 519-541) disagreed with every one of the Kris' Study Group's findings.
Greenson maintained that "…one cannot carry out genuine analysis in
sufficient depth if one does not understand the structure of dream
formation as well as the patient's and the analyst's contributions to the
technique of dream interpretation (Greenson's italics)." Greenson
asserts that free associations are rarely achieved by most patients and
are defended against, that slips of the tongue occur rarely and are also
defended against, and that acting out is by definition ego-syntonic and is
strongly rationalized away. He states,
"By contrast, as bizarre and
incomprehensible as the dream may appear, the patient recognizes the dream
as his, he knows it is his own creation. Although the strange content of
the dream may make it seem alien, nevertheless it is irrevocably his, like
his symptoms, and he is quite willing to work on his dreams, provided his
analyst has demonstrated how working together on dreams is helpful in
achieving greater awareness of the patient's unknown self."
VI. Description of dream
from a patient: the dream of wife-mother transmutation
I will next describe a dream from a patient
of mine with the intent of illustrating the use of dreams in contemporary
psychotherapy. It is not unusual for me to carry out a session centered
upon a patient's associations to a dream. What follows is a very recent
dream from a patient in therapy with me for much of the preceding 7 years.
He is the successful founder of a profitable business, which he recently
sold for what is to everyone in this room a large sum. He is in his early
40ies, is married with a young family. He and his wife have been in
marital therapy with Dale Godby. When he started therapy with me, he was a
single, addiction-prone, conflicted employee of a medium size corporation.
He is very sweet, considerate, and likable.
"I dreamt I saw my wife and my mother
changing back and forth into each other. It was just the face of my wife
or my mother in front of me. I could see my mother's image appear through
my wife's, then back again, sort of like one coming into focus and the
other fading, then changing back again."
The patient's associations: The patient
dreamt the above the last morning of trip to Hawaii, just before leaving
the island of Maui. The trip was a very enjoyable, he maintained, but he
and his wife had several conflicts. Their plane to San Francisco was late
and they missed their connection to Maui. They and their two children
spent the night in San Francisco. When they arrived at the airport the
next morning, there were no direct flights to Maui. They could only
connect through Honolulu. The airline forgot to include the price of the
connecting flight in their fare. The patient's wife wanted to get the
tickets corrected before they left the counter, although the plane was
boarding. The patient states, "I just wanted to get on the plane and
take care of it later. But she insisted. We got into a discussion in front
of the ticketing agent who didn't know which one of us to listen to. I
convinced her to get on the plane at the last minute."
The patient states, "Where we stayed
on Maui was like a desert, a fancy resort on the beach with nothing near
us. One night I wanted to eat at the hotel but my wife wanted to go to a
restaurant that I knew was an expensive tourist trap. But she insisted and
we went there. It cost a fortune and the food was really bad, just a lot
of junk heaped on a big plate."
The patient associates: He used to go to
Hawaii with his mother and father, after his brother and sister had left
for college. His mother was very anxious about flying, and preparations
for the trip were always very trying. Packing was an ordeal. If they
weren't an hour early, his mother was certain they had missed the flight.
When they got to Hawaii, his mother would go off shopping by herself and
the patient would go to the beach with his father, who ogled girls, while
the patient played in the water.
His associations continue: when in grade
school, each morning his mother would cook breakfast for himself, his
brother and his sister. It was always tense, his mother was in a hurry to
get everyone off to school. At any moment, his mother was either talkative
or depressed, depending on where she was in adjusting her blood-alcohol.
The patient always felt responsible for her downcast mood as he does his
wife's. He also feels angry their moodiness. He is in a marriage more
similar to his childhood than he had wished.
He associations proceed: his father was a
bomber pilot in World War II, in the Pacific theater, and was shot down in
a disastrous battle, in which most American planes were destroyed. His
father became a prisoner of war until he was liberated by the Russians
following the Japanese surrender. Recently, when his father got in touch
with another survivor of the plane crash, that individual was still angry
at the patient's father. He maintained that it was because the patient's
father was drunk that the plane was shot down. This is the earliest
reference the patient had heard of his father's alcoholism, which
continues to this day, 56 years later. The father has been an active
alcoholic from then until he was convinced by his children to enter an
assisted living facility with 24 hour personal help, where he continues to
have the staff sneak him an occasional pint. My patient mentions that his
father is a tall, slender, and distinguished looking, with a full head of
hair that shows no gray. My patient is medium height and slightly
overweight.
The patient continues: his father returned
to Dallas at the end of World War II and worked as an executive for a
start-up airline. The patient's father was a friend of the airline's
founder. Although the father's drinking undoubtedly interfered with his
advancement, it was apparently accepted, as he remained an executive for
the airline until its bankruptcy in the early 1980ies. His negotiated
international plane routes and would disappear into Asia or South America
for weeks at a time. The patient assumes his father was having affairs on
these trips, with good reason. The patient states he saw through his
father's deception. The father's transcontinental trips were special times
for the patient to be alone with his mother. His father had a way of
equivocating with evasive half-truths which the patient strongly abhors to
this day.
Dream analysis: In contrast to Freud's
dream of the botanical monograph, at least one level of meaning of this
dream of wife-mother transmutation is transparent from the dream image.
The patient resists Oedipal interpretations. I interpret the patient's
wish to be rid of his father, and for the patient's mother to recognize
that her son was more trustworthy, despite the father's heroism and high
profile profession. The patient talks about his mother's alcoholism and
how much she and his father enjoyed getting drunk together. The patient
states he was and is more responsible than either of them, both of them
were slippery and elusive. His anger at this Oedipal defeat is palpable.
The patient says he married a woman with some of his mother's least
desirable characteristics. He says he is seeking the approval of both
faces in the dream, each expects him to fix their depressed moods, this is
his responsibility in life. He expects each of them to be upset with him.
His lot in life to take care of the emotional needs of the women he loves.
In summary, the dream is productive in dealing with current conflicts and
lays the groundwork for future Oedipal interpretations.
VII. The sleep
laboratory investigation of dream content.
In this section I describe some findings
from sleep research laboratories to provide a flavor for the
psychodynamically useful discoveries that have emerged recently. The
laboratory investigation of dreams has enabled the establishment of some
specific relationships between dream content, memory, personality, and
emotion. For example, intense emotional experiences of the day (Piccione
et al., 1977) and the thoughts one has before going to sleep (Kramer,
Moshiri, and Scharf, 1982) are represented in the night's dreams. This is
similar to what Herbert Silberer reported in 1909 from a series of studies
in which he forced himself to awaken soon after falling asleep. He
described how the thoughts he had immediately preceding sleep were
transformed into vivid hallucinatory images immediately after he began to
sleep. He termed this the "autosymbolic" phenomenon, and saw it
as the link between waking thought and what Freud had described as the
dream work.
Laboratory studies have also shown a
thematic continuity between the dreams of a given night and spontaneous
verbal behavior the following morning (Kramer et al., 1982). In general,
one wakes up feeling more friendly and less unhappy than one felt prior to
sleep (Roth, Kramer, and Roehrs, 1976). The dimension that correlates most
closely in a given subject from one day to the next is the unhappiness
dimension of mood: one has a tendency to awaken feeling a similar degree
of unhappiness each morning.
Knowing nothing about an individual
dreamer, judges are able to separate the dreams of one night from those of
another night (Kramer, 1993). When judges are given dreams from several
subjects, they are able to sort the dreams into a group for each subject.
The judges are able to perform this sorting without any knowledge of the
dreamer.
Similar to what Freud described, laboratory
studies show that the dreams of a night are mostly focused on a single
topic. The emotional preoccupations and current concerns of the dreamer
are correlated with the content of the night's dreams. The content and
emotions expressed in TAT stories and dreams from a given individual are
similar (Kramer, McQuarrie, and Bonnet, 1981). If a TAT test is given to
an individual before sleep and again in the morning, the responses are
similar to the dream content reported from REM awakenings during the
intervening night of sleep (ibid.).
Laboratory studies have also shown that
mood changes systematically from night to morning, with a greater sense of
affability and less unhappiness upon morning awakening. If one is sleep
deprived, the opposite outcome is observed, with markedly worse mood in
the morning. One can assume then, that mental processes occurring during
sleep are responsible for the increased sense of pleasantness and
satisfaction that normally follow a night of sleep (Kramer, 1993). Sleep
and dreams, one may conclude, have been successful when one awakens with
improved mood.
VIII. The neurobiology
of dreaming
In this section, I describe some
neurobiological findings relevant to dreaming which I have specifically
selected because of their clinical applicability. I look forward to
discussing your impressions of the relevance of this material. During REM
sleep, various centers in the brain show increased activity and their
neurons fire in patterns more similar to waking than to NREM sleep. Alan
Hobson and Robert McCarley, among others, traced the cortical activation
back to the triggering events, which they observed to be in brainstem
structures, namely the pons. They and others have shown that a cat's
cortex could be removed, yet all the manifestations of REM sleep in the
remaining brain continue to be present. However, REM sleep is totally
abolished if areas of the pons are removed, even with an intact cortex.
This suggests that the brainstem is necessary and sufficient for the
occurrence of REM sleep. Various investigators have shown all
manifestations of cortical activation are preceded by several milliseconds
by discharges in brainstem centers.
In what is called the activation-synthesis
model of REM sleep, Hobson and McCarley assert that dreams are an
accidental byproduct of cortex's attempt to synthesize incoming volleys of
stimulation originating in the brainstem. The properties of dreams can be
explained most parsimoniously by assuming that the cortex is attempting to
integrate virtually random barrages of electrical excitation. The model
they proposed is called a bottom-up approach, in that the primary
instigation of the dream is located in the brainstem. This is in contrast
to a top-down model, in which the dream is viewed as a product of the
cortex, with ancillary brainstem discharges. Hobson and McCarley contend
that the bizarre nature of dreams as well as their discontinuous nature is
not due to the dream work proposed by Freud, but are the products the
cortex trying to make sense of storms of random electrical activation.
A recent study by Robert Stickgold has
shown that both normal subjects and amnesiacs, with no declarative memory,
incorporate procedural memories into their sleep onset mentation, and
probably into REM dreaming. Amnesiacs describe images similar to the
computer display they practiced during the day. This same study showed
that both normals and amnesiacs performance on a procedural task improved
markedly after a night of sleep. The task is the computer game Tetris. I
have tried playing this game and quickly hit a ceiling, a high score upon
which I could not improve. Following a night of sleep, my score more than
tripled, similar to Stickgold's results. Various studies have shown that
after a night of sleep subjects improve on a variety of procedural tasks
but do not improve on tasks involving declarative memory. This suggests
that sleep is more important for the consolidation of procedural than
declarative memory. It appears as if REM sleep might be associated with
rehearsal of procedural memories.
Positron emission tomographic (PET) images
of the dorsal-lateral prefrontal cortex show that neural activity in this
region decreases greatly during REM sleep. The colored images of brain
sections from publication's by Braun's and Maquet's groups display dark
blue colors in prefrontal cortex during REM sleep, signifying deactivation
in these centers, compared to the orange and yellow colors representing
heightened activation during NREM sleep and waking. This is the region of
brain most closely associated with executive function, or the higher
cortical functions of integrating and sequencing behaviors as well as
interpreting and controlling emotions. Many regions of the brain increase
their activity during REM sleep, especially the limbic system, which
underlies emotion, the hippocampus, related to memory, the occipital
cortex, associated with visual imagery, and the visual association areas
of the parietal cortex, which link meaning to images. However whole brain
activity is measured, it is as active during REM sleep as it is during
waking under conditions of extreme activation, far greater than when the
brain is at rest.
Louie and Wilson recently demonstrated that
if one records from electrodes implanted in the hippocampal neurons of a
rat's brain, the patterns of activity that are observed over minutes, when
a rat is learning a maze, are replicated when the rat is in REM sleep
(Louie and Wilson, 2001). This replication of patterns of neural activity
during REM sleep is to the extent that one is able to surmise where the
rat would be if the rat were in the maze by observing hippocampal neural
discharge during REM sleep (Louie, K, NPR interview, 2001).
CONCLUSIONS
Freud believed that his breakthrough
discovery was that dreams express wish-fulfillment. He believed this to be
the signal discovery of his career. A century later his most enduring
contribution to dream interpretation might be the technique of free
association and the concept of a latent meaning, not his wish-fulfillment
theory.
What have we learned since Freud, and is
what is its clinical significance? First, we have learned much about the
universality of the REM state: dreaming is more ubiquitous than had been
conceived, from earliest childhood memories through one's final night of
sleep. We have learned that what we are preoccupied with prior to sleep
makes its way into our dreams. We know that our entire night of dreaming
focuses on one or a few major themes. We know that the dreams of each
individual and the dreams of each night of sleep, to some extent, have
their own, identifiable signature. We know now that dreaming has a biology
that correlates with its phenomenological attributes. The mind continues
to dwell upon the thoughts of the previous day during much of a night of
sleep, thoughts which are probably distorted due to the deactivation of
cortical areas responsible for logical, hierarchical thinking.
The modern neurobiological-model of brain
activation during REM sleep from imaging studies is in many ways
consistent with Freud's description of mental functioning during dreaming.
What he termed primary process thinking was hypothesized to be illogical,
wish driven, perceptual, and deliberately distorted. In Chapter VII of
Interpretation of Dreams he described in detail the manner in which a web
of associations and memories are at the disposal of the mental apparatus
during dreaming. His description is in many respects a phenomenological
equivalent of the deoxyglucose imaging studies of neural activity during
REM sleep, which show executive function centers to be deactivated while
emotional, association, and visual systems are activated.
Freud maintained that dreams are based on
seemingly inconsequential memories from the preceding day. Louie and
Wilson (2001) showed that the firing patterns of certain cell ensembles
during REM sleep replicate firing patterns during learning. This finding
corroborates that procedural memories are reactivated during dreaming and
amounts to a neural documentation of Freud's day residue theory. These
same procedural memories might well be viewed as inconsequential to our
waking mind.
From Freud's botanical monograph dream it
is apparent that much of dream analysis using his approach consists of
establishing connections between previously disconnected thoughts. Such
connections might be thought of as helping the patient establish extended
cell assemblies between distant neural populations, connections imbued
with meaning, motivation, or resolution of conflicts. The so-called latent
content of the dream might frequently be the patient's associations which
are, for the most part, conscious, warded off thoughts. Dream
interpretation aids the patient in the formation of associations between
fantasy, memory, wishes, and motives.
Dream interpretation today is as
significant in psychotherapy as it was in Freud's time. The dream might
not be the royal road to the unconscious, but its successful analysis is a
certain path to therapist and patient working in a therapeutic alliance.
When a patient reports a dream, it is, as Levy suggests, an act of courage
and of hope. The patient, in every instance, is telling the therapist that
there is a product of his or her mind that is not fully understood, in the
hope that the therapist can help unravel it. To do so is to engage in a
process in which the therapist and patient work collaboratively, a process
involved in the experience of insight, the engine behind psychotherapeutic
change.
I hope the above description of the
neurobiological and psychoanalytic approach to dreams is in some ways
helpful to your in work with patients, or at least interesting and
informative. I would like to learn from some of you in what ways you use
dreams in your work with patients. Thank you.
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