#76523: Dream Work: A Psychoanalytic Perspective

The nature and meaning of dreams has been an area of interest throughout history. However, Sigmund Freud elevated the study of dreams to a type of science. His contributions, including the concept of the unconscious, remain relevant to researchers and mental health professionals today. With the publication of Freud's The Interpretation of Dreams, the field of psychoanalysis was born, and serious clinical inquiry into the basis and creation of the mind (i.e., Freud's "theory of the mind") began. Freud labeled the ethereal parts of the mind (i.e., the conscious, subconscious, and unconscious) that make us human, and he established the foundation for how we think about the brain. His theory of the mind led to the understanding that our dreams are both purposeful and meaningful [1].

While sleeping, dreams seem real. On waking, however, the memory of the dream, especially in comparison with waking thoughts and feelings, may seem alien or other-worldly [2]. Freud connected these impressions to the explanation that dreams are messages that begin outside ourselves. Literature is filled with examples of dreams explained as communications from supernatural or divine sources, understood as warnings or predictions [3,4,5,6,7]. Cryptic dreams have been explained as needing only the wisdom of a gifted interpreter to decode the message [6,7,8]. Conceptualizing dreams as supernatural messages means that questions of the dream's origin, content, meaning, and function are quickly answered. However, this discourages the pursuit of scientific study and dismisses dreaming as unimportant meandering of the mind [9]. Freud asserted that dreams are meaningful, and that, although their meanings are hidden, a replicable method for uncovering their meanings is possible. His confidence in the value of dreams echoes the attitude expressed throughout history: rather than simply being contrasts to waking life, dreams have value, command attention, and deserve efforts to find their meanings.

Many contemporary experts support Freud's assertions about the meaning of dreams, detailing neuroscientific findings consistent with basic psychoanalytic concepts, including the hypothesis that dream content is disguised by censoring operations in the mind. As Solms states, "We are beginning to understand something about the neurological correlates of the censoring function, and we know at least that the structures which are most likely to be implicated are indeed highly active during dreaming sleep" [9]. Others, while acknowledging that dreams have purpose, argue against interpreting dreams. They have abandoned the concept of hidden meaning, attending only to a dream's literal narrative and the feelings it induces [10]. Regardless of one's position on the meaning of dreams, critics and supporters alike have evolved from Freud's scientific approach to the study of dreams, an approach that was influenced by Charles Darwin, Ernst von Brücke, and other great scientific minds.

Freud was an accomplished neurologist with 28 publications to his credit before he began psychoanalytic work, but in spite of his achievements, he was frustrated in his efforts to gain an appointment as full professor at the University of Vienna. He was Jewish, and anti-Semitism stifled academic and professional advancement in 19th century Vienna. Eager to marry, and pressed by financial responsibilities, Freud needed a reliable income. His colleagues advised private practice. Unprepared for clinical work, however, he returned to study, traveling to Paris to work under renowned neurologist and psychiatrist Jean Martin Charcot.

Charcot was a commanding and masterful teacher, challenging prevailing theories of the day. In an era when hysterical symptoms were dismissed as a form of malingering, Charcot experimented, and obtained remarkable results, with hypnosis. He recognized hysteria as a real ailment afflicting both men and women. His methods also demonstrated that hypnotic states were genuine phenomena that could be used to heal otherwise intractable complaints. Charcot insisted that everything about his clients' hypnotic reactions was significant, including a peculiar "magnetic passion" developed for the hypnotist. (Freud eventually understood and named this behavior, transference, one of the most powerful of psychoanalytic phenomena.) What interested Freud most about Charcot, however, was his confidence in plain, observable facts as opposed to dogma. Charcot taught Freud that the "scientist's submissive obedience to facts is not the adversary, but the source and servant of theory" [11]. Returning from Charcot's clinic in 1886, Freud began a practice in neuropathology. With it began discoveries that would change the scientific understanding of human behavior.

Like any young physician, Freud looked to established colleagues, such as Josef Breuer, for referrals. Breuer was a reputable neurologist (credited with discovering the role of the vagus nerve in controlling respiration) who, like Freud, had abandoned the laboratory for private practice. Breuer and Freud also shared interests in psychopathology. Their 1895 publication Studies On Hysteria introduced the cathartic "talking cure," which gradually evolved into psychoanalysis. Another physician friend, Wilhelm Fliess, became increasingly important to Freud. Fliess (an ear, nose, and throat specialist) was indispensable to Freud, especially as Freud was writing The Interpretation of Dreams. Fliess had a sound understanding of Freud's theories as well as an appreciation for psychologic themes common across cultures. Freud prized Fliess' ability to accept as scientific evidence all types of human behavior, including folklore, legends, and dreams [11].

With experience in private practice in hand, Freud began lecturing and writing on the origin and treatment of psychoneuroses and hysteria. In an 1896 presentation for Vienna's Society of Psychiatry and Neurology, he confidently announced that all hysterias are founded in repression, always with a sexual content. Expanding this argument, Freud declared that hysterical illnesses originate with a passive sexual experience (i.e., a seduction) that occurs before puberty, usually at 3 or 4 years of age. He based his conclusion on 13 successful cases, all carefully documented. He stated that students of hysteria are like explorers discovering the remains of an abandoned city, and when obscured inscriptions (i.e., clients' repressed memories and feelings) can be uncovered and read, then the truth and symptom relief will follow. Freud found much criticism and little support for this assertion, however. Dismayed, angered, and discouraged, Freud experienced a period of pessimism. He continued treating neurotic clients successfully and maintained his belief in the sexual origin of their illnesses. Bolstered by Fliess and spurred by his own practice of observation and common sense, Freud eventually re-examined his initial conclusions and found a deeper truth. He recognized that his clients' reports were serious but not literal communications, and he began to listen more intently. He came to read these reports as messages that were coded: distorted, censored, and meaningfully disguised [11]. Helping his clients to discover and meaningfully illuminate these unconscious activities formed the basis for Freud's theory of the mind.

Spurred by the death of his father in 1896, Freud began an intense self-analysis. He knew that what he was learning from his work with clients revealed information basic to all human psychologic development, and he realized that his own development could be no exception. Armed with the same objectivity that he brought to dissections in von Brücke's laboratory, Freud analyzed his dreams, his physical symptoms, his inhibitions, and his wishes. In this way, he became a model for future psychoanalysts and set the standard for competency: to analyze, one must first submit to analysis.

Freud's approach to dreams includes the assertion that their meanings are hidden; they are disguised expressions of suppressed wishes [1,2]. Exploring unconscious mental activity was at the heart of Freud's approach. In his view, dreams are the direct result of unconscious activity that helps determine a dream's production and its final form. It is by uncovering these unconscious thoughts that a dream's meaning can be revealed, a process that requires the dreamer to willingly suspend self-criticism and censorship.

Censorship is the agency that watches critically during sleep, rejecting many thoughts and forbidding expression. It regulates which thoughts and wishes are permitted to reach consciousness. Wishfulness is the psychologic agency that presses for expression against censorship. A third psychologic agency, the ego, evolves. Sleep dulls the censor, allowing ideas that have been rejected in waking hours to slip through, finding disguised expression in dreams. Dreams answer the ego's wish to sleep; dreams sometimes fail, however, and the dreamer awakens. Physical stimuli that occur in sleep must be interpreted by the brain in a way that will not wake the sleeper. Occasionally, the sensations are too intense or the disturbing ideas are too poorly disguised to permit sleep to continue. Anxiety dreams—those frightening visitations that jolt dreamers awake—are partly explained in this way.

Freud considered dreams to be "the royal road to the unconscious" [2]. One of the first dreams that Freud understood to be meaningful was his own "Dream of Irma's Injection." Freud described his dream in this way [2]:

A great hall—a number of guests, whom we were receiving—among them Irma whom I immediately take aside, as though to answer her letter and to reproach her for not accepting my "solution." I say to her: "If you still have pains, it is really only your fault." She answers: "If you only knew what pains I have now in the throat, stomach, and abdomen – I am choked by them." I am startled and look at her. She looks pale and puffy. I think to myself that after all I must be overlooking some organic affection. I take her to the window and look into her throat. She offers some resistance to this, like a woman who has a set of false teeth. I think, surely she doesn't need them. The mouth then opens wide and I find a large white spot on the right, and elsewhere I see extensive grayish-white scabs adhering to curiously curled formations, which are evidently shaped like the turbinal bones of the nose. I quickly call Dr. M, who repeats the examination and confirms it…Dr. M looks quite unlike his usual self; he is very pale, he limps, and his chin is clean-shaven…Now my friend, Otto, too, is standing beside her, and my friend, Leopold, percusses her covered chest and says: "She has a dullness below, on the left," and also calls attention to an infiltrated portion of skin on the left shoulder (which I can feel in spite of the dress)…M says: "There's no doubt it's an infection, but it doesn't matter; dysentery will follow and the poison will be eliminated." We know, too, precisely how the infection originated. My friend, Otto, not long ago, gave her when she was feeling unwell, an injection of a preparation of propyl, propyls…propionic acid…trimethylamin (the formula of which I saw before me, printed in heavy type)…One doesn't give injections of that sort ought so rashly…Probably, too, the syringe was not clean.

Freud's study of dreams founded over a century of psychoanalytic research and practice. It marked the beginning of his drive theory, which began with the premise that human behavior is determined by biologic drives that operate outside consciousness. Freud concluded that the greater part of psychologic life is unconscious. Sexual and aggressive strivings, he found, are central motives throughout life; illnesses can begin with their repression. He described the sexual life of children, including the Oedipus complex, and noted that childhood sexual fantasies and experiences have a determining effect on adult character and personality. Each of these tenets is rooted in clinical observation and in the analysis of dreams.

In addition to Freud's formulations, at least four additional, distinctive psychologies exist within psychoanalysis, each emphasizing specific aspects of human development and function. Ego psychology, closest to Freud's drive theory, describes adaptations developed in response to conflicts between internal drives and external realities. Freud's daughter, Anna, a gifted analyst in her own right, named these adaptations "defense mechanisms" and created the terminology so familiar today (e.g., denial, repression, projection, identification). Ego psychologists emphasize the importance of studying normal ego functioning, defined as efforts "to achieve the maximum degree of drive satisfaction consistent with the limitations imposed by the environment" [20]. These theorists point to the ego's functions in the outside world (e.g., thinking, learning, impulse control) and note that sexual and aggressive drives can be redirected. Like Freud, ego psychologists value dreams for their revelations of thoughts hidden in waking life.

Object relations theorists believe that individuals develop prototypes of interpersonal relationships that are repeated throughout life. Objects achieve internal psychic representation as well as external influence. The theorist might argue, "There is no such thing as a baby…There is only a baby with a mother" [21]. Total dependency characterizes the early years of human development, and the resulting attachments have an enduring influence. Object relations theorists describe deficits that can develop if early objects are inadequate; they also describe corrective (e.g., therapeutic) experiences that create change. An object relations approach gives special attention to dream references that describe clients' reactions to their analyst.

Eminent psychoanalyst Heinz Kohut identified the self as the all-important structure of personality. Self develops from one's experiences both in subjective and interrelated situations. It is a concept more directly related to individual experience than are the concepts of drive, ego, or object. Self psychologists emphasize the importance of achieving a cohesive sense of identity and autonomy; threats to this secure sense of self bring fear of personal disintegration. The experience of empathy, both in the course of early development and later in therapeutic relationships, is central to healthy self-development. Like Freud, Kohut felt that most dreams hold wishes, but he added the concept of self-state dreams. Self-state dreams are generally believed to be an effort to master or integrate threatening psychologic material, much in the way that traumatic dreams are processed.

Dream work is a departure from classical dream interpretation, which explores the images and emotions evoked without focusing on a single meaning of the dream. Through dream work, one learns about oneself, often with the help of others. Sharing dreams in small, empathic groups has been shown to increase dreamers' associations and insights and promote healing [22,23]. Dreamers and listeners are equally capable of accurate understanding. Dream workers use ideas from many sources, including Freud and Jung; they do not necessarily feel that therapists are required. Dream workers' contributions include group techniques, methods for recalling and recording dreams, and validation of dreamers' interpretive expertise. Many also include spiritual discussion in their approach [24].

Differences within psychoanalysis need not challenge its validity. Rather, bringing diverse approaches to dream analysis supports the validity of psychoanalysis while adding value to the practice of dream analysis. In one study, analysts with four different orientations each interpreted a patient's dream. Although their interpretations differed, all were found to be correct and all indicated the existence of a major psychodynamic issue that emerged over the course of the patient's seven-year analysis [25].

Researchers remain challenged by the psychologic issues identified in Freud's time and before. Determining the meaning and origin of dreams, addressing the problem of recall, unraveling the mystery of content, and accounting for dream function are all issues that continue to be researched and discussed. Research examples come from psychology, neuropsychology, psychoanalysis, and neuroscience.

Psychoanalysts generally share an approach that includes free association (i.e., the patient's unreserved report of ideas, memories, feelings), dream interpretation, interpretation of resistance, and interpretation of transference. Resistance refers to both the conscious and unconscious efforts that clients make to counter therapeutic progress. Transference recognizes the patient's tendency to perceive the analyst as an important figure from the patient's past. Analysts also consider countertransference (i.e., both conscious and unconscious feelings stirred in the analyst by the patient). Creating a therapeutic alliance, respecting and understanding the ego's defense mechanisms (characteristic and/or transient means of adjustment), and strengthening ego functions are additional common aims. Many psychotherapists recognize these processes and use this language.

Dreams are an integral part of daily life across cultures. Although the biologic and physiologic framework of dreams is consistent throughout the world, the importance, validity, and value placed on dreams differs [32,33,34,35]. Research indicates that although both Eastern and Western cultures place certain validity on dreams, Western cultures more readily determine dreams to be a product of the brain without having greater meaning [35,36]. Western cultures often view dreams, and the act of dreaming, as unreal and unimportant, viewing waking life as the only true "reality" [37]. Many contemporary psychologists hold this to be true, asserting that dreams merely sort memories. They believe that dreams are a reflection of the organization of an individual's thoughts and daily experiences and how these thoughts and experiences relate to the individual's physical, emotional, and social life [38].

In contrast, many Eastern cultures view dreaming either as an opportunity to connect with another realm of "reality" or as a tool to spiritually progress [37]. Tibetan Buddhists practice a meditative dream state called dream yoga, whereby they use their dreams to assess inner sources of suffering [39]. Dream yoga is a meditative practice in which the dreamer maintains a dream state while being lucid. Both dreaming and waking states are considered equally real or unreal; thus, dream yoga practitioners are able to use these dreams to assess individual sources of unhappiness. By determining the source, they are able to address their own discontent and ultimately live a happier life with a greater sense of peace [39].

Other cultures view dreams as spiritual phenomena connecting the dreamer to spirits, nature, and other dimensions outside their waking reality. In Native American cultures, dreaming connects the individual to spirits, providing a compassionate understanding of dimensions outside present reality [39]. In the Ese Eja community in the Peruvian Amazon, dreamers "see" the names of their unborn children in dreams, showing a direct indication of the importance placed on the dreams themselves. The Ese Eja perception is that reality and dreams are intertwined and overlapping in time and space [40]. In some instances, the lack of adequate dreaming is seen as a detriment to a community and its livelihood. In the Andamanese hunter-gatherer culture in India, dream sharing is practiced within the community in order to form a consensus on the meaning of an individual's dreams. Once they have arrived at a consensus, these dreams determine actions taken by the community in waking life. Andamanese people believe that more modern sleeping arrangements, with less time devoted to the understanding and recollection of dreams, is the reason for their declining hunting success [41].

Another component of dream analysis is the connection between how an individual interacts with virtual media (e.g., videos, MP3 players, video games) and how the images of these media can affect the individual's dreams. Research indicates that the more an individual interacts with a specific type of virtual media, the more that media will affect and be present in the individual's dreams. The most direct connections between virtual technology and dreams are seen in clients who regularly watch films and/or play video games. Body systems simulate movement and establish spatial orientation function during dreaming as they do when viewing a film or playing a video game [46]. The greater the degree of interactivity and clarity of the images in the media, the greater the likelihood that those images will appear in dreams [46,47]. Also, the more regular the participation in virtual reality media, the stronger the connection between waking life and dream life emotions. Researchers have also documented specific connections between media and manifest dream content. A survey of nearly 1,300 Turkish dreamers revealed that those who consumed violent or sexual media were more likely to produce dreams with violent or sexual content and experienced greater dream frequency [48]. A pilot study of persons experiencing nightmares found that treatment combining virtual reality technologies with imagery rehearsal and rescripting was effective in reducing anxiety, nightmare frequency, and post-traumatic stress symptoms [49]. Media is a ubiquitous element of both waking and dreaming life. As such, clinicians should be aware of patients' media activities and should acknowledge the potential role of technology as a therapeutic tool [46,47].

Few clinicians will approach Freud's virtuosity, and this level is not required to achieve useful insights. The following are examples of ordinary dreams and ordinary, but important, applications. Dreams I and II are the author's; dreams III and IV belong to clients in the author's practice.

Freud affirmed that dreams are meaningful and that they originate within the dreamer. He explained that a dream results from a struggle between an unconscious wish and forces opposing that wish. A dream occurs because its disguise—its manifest content—hides latent objectionable thoughts from the mind's censoring operations. Disguised, nonsensical content reduces disturbance and permits sleep to continue. Analysis uncovers the dream's latent meaning and reveals motives, thoughts, feelings, and memories otherwise unknown to the dreamer. With publication of The Interpretation of Dreams, Freud demonstrated his method, introduced psychoanalytic theory, and launched decades of research and clinical innovation.

Research supports the meaningful nature of dreams, finds neurologic evidence of wishful brain activity during dreaming, and suggests that even traumatic dreams have a wish-filling function. Divergent views within psychoanalysis enrich therapeutic work and stimulate thought. Freud's analysis of his own dreams set a standard still central to psychoanalytic training: to analyze, one must first undergo analysis.

When interpreting a client's dream, the clinician should consider the effects that culture, race, and technology have on the images present in dreams as well as on interpretation of the individual's dream. Assessing and interpreting dreams should always be an open, communicative process between the psychoanalyst and the dreamer. It is important to note that dream work is not limited to psychoanalysts or therapists; any dreamer can use Freud's method (i.e., suspend self-criticism, collect thoughts and associations clinging to dreams). Dream work can advance the therapeutic alliance, produce new insights, and build clients' ego strength. Analysis of one's own dreams sharpens clinical skill and promotes essential self-knowledge. Technique calls for candor from the dreamer, self-restraint from the clinician, and patience, curiosity, and hard work from both.