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.

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.

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.

Freud discussed his associations to the Irma dream in The Interpretation of Dreams, in which he examines the dream image by image, ponders the meaning of the various thoughts that come to his mind in connection with each image, and begins to notice a recurrent theme. Although the dream presents a number of different explanations for Irma's pains, it portrays Freud as utterly blameless. Freud concludes that the dream shows how he wishes things were (i.e., blameless for Irma's pains). Thus, the wish was the dream's motive, and the dream represents the wish fulfilled. The "secret" revealed to Freud through the Irma dream is that dreams are the fulfillment of wishes. In response to opponents who questioned how a terrifying nightmare could possibly be the fulfillment of a wish, Freud responded that it was important to distinguish between the dream's manifest content and its latent content [1,12,13].

Freud asserted that dreams embody two levels of meaning or content: manifest and latent. He defined manifest content as that which the dream relates; it is the dream as dreamt and consciously remembered by the dreamer. Manifest content more often consists of visual images than thoughts and words. It is the surface meaning of the dream that is reported on waking (e.g., you dream you are running, but when you look behind you, no one is there); it is a disguised representation of the true thoughts underlying the dream. These underlying thoughts are what Freud called latent content, consisting of unconscious wishes and fantasies that have been denied gratification. Latent content is the deeper, hidden, symbolic meaning of the dream. It is the disguised, repressed part that translates threatening, underlying impulses (e.g., unconscious sexual, aggressive impulses) into the more acceptable manifest content. Latent content is disguised by a censorship process into manifest content. Because latent content is repressed, and therefore unobtainable by the dreamer's consciousness, it is accessible only by the analysis of ideas. The process of transforming unconscious latent content into acceptable manifest content is called dream work [14,15,16,17,18].

Dream work takes the raw material of dreams (e.g., memories, feelings, wishes, events of the day) and combines it to analyze a dream [1,13,18]. This is carried out through three primary types of transformation: condensation, displacement, and secondary revision. Condensation refers to dreams' compression of many associated thoughts, memories, fantasies, and images into a single figure. There are different types of condensation, each with an everyday application. Videos that combine two images into a new composite image, disparate individuals that form groups based on a commonality, slips of the tongue, and double entendre jokes are examples of condensation at work in everyday life.

Dream work takes the raw material of dreams (e.g., memories, feelings, wishes, events of the day) and combines it to analyze a dream [1,13,18]. This is carried out through three primary types of transformation: condensation, displacement, and secondary revision. Condensation refers to dreams' compression of many associated thoughts, memories, fantasies, and images into a single figure. There are different types of condensation, each with an everyday application. Videos that combine two images into a new composite image, disparate individuals that form groups based on a commonality, slips of the tongue, and double entendre jokes are examples of condensation at work in everyday life.

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 a 2010 study examining the meaning and content of dreams, researchers used sophisticated quantitative methods to organize dream data [26]. They hypothesized that dream content could be read in a way that would accurately reveal the dreamer's daytime interests, personality traits, aspects of relationships, and overall emotional well-being. They predicted that dreams would echo waking life and that their meaning could be found by examining manifest content (i.e., the dream as recalled by the dreamer) without additional interpretation. The investigators examined dreams using a combination of the Hall/Van de Castle (HVdC) system, a content coding system that provides normative data for the content of adult dreams, and a related but newer, computerized word-search method. The data were drawn from 192 reports collected in a journal over a two-year period, contributed by one dreamer, a male volunteer 23 years of age. The young man, a journalist, contacted one of the researchers and requested help interpreting his dreams. Dream reports, recorded in a Word document, were loaded into a computer dream bank and analyzed for content using HVdC categories and the researchers' previously published word strings (40 categories of words and phrases known to capture dream content). One of the researchers was designated to make blind inferences from the data; he did not read the dreams nor was he privy to any biographical information about the dreamer, beyond age and sex. He produced 14 inferences about the dreamer based entirely on frequencies derived from the computer's sorting. Each of these inferences was expressed in descriptive sentences and given to the dreamer for comment. For example, "He is socially active and competent, not reclusive or shy;" "He is an even-tempered person, not prone to emotional outbursts;" and "He is closer to his brothers G and J than brother C or sister A" [26]. The dreamer confirmed 12 of the 14 inferences. The researchers concluded that a blind analysis of dreams based only on the results of word searches could accurately predict many aspects of an individual's waking life (e.g., personality attributes, relationships, activities, cultural preferences) [26].

Memory, an issue central to dream study, has been scrutinized by neuropsychologists who have explored the acceptability of data from dreamers' reports, the best setting for collecting dream specimens, and the role of rapid eye movement (REM) sleep in dreaming [28]. The goal of one meta-analysis was to determine whether the methods researchers use to study dream recall affect the outcome or whether recall is innately difficult [28]. Dream recall measured with self-rating scales found average frequencies of two to three dreams per week; however, the results were not consistent. (This is partly because the term "recall" can be interpreted differently.) Indeed, when taking into account so-called "white dreams" (i.e., the certainty of having dreamed but not being able to recall the dream content), the rate of dream recall was an average of 5.1 dreams per week (up to 72.9% of spontaneous awakenings) [28]. This indicates that people are regularly aware of their dream experiences, irrespective of their ability to recall dream content.

Neuroscientists describe dreaming as a regressive process. That is, dream images result from information or stimuli traveling backward in the perceptual system. (Sleep blocks passage forward and prevents motor activity.) These images are fed into the cortex as if they were coming from the outside. The brain system that processes incoming stimuli responds to this reversal by converting the information into visual images instead of waking thoughts. Because critical or reflective functions are inactive in sleep, the images are mistaken for real perceptions. Freud wrote extensively about the regressive nature of dreams. He acknowledged that science in his time could not trace precise pathways for dream activity but stated confidently that "deeper research will one day trace the path further and discover an organic basis for the mental event" [2].

As with many mental health disciplines, psychotherapists' preparation includes years of postgraduate study and hours of supervised practice. Course content and supervisory requirements vary by university, by discipline, and by professional license. Psychoanalytic candidates, regardless of professional license or previous study, have an additional requirement to complete a personal analysis before earning the title of psychoanalyst. Psychoanalytic training institutes define their own curricular and supervisory standards, but all demand a personal analysis, which is unique to this profession. The National Association for the Advancement of Psychoanalysis (NAAP) requires its members to have a minimum of 450 hours of course work, 1,500 hours of supervised clinical experience that includes 200 hours of psychoanalytic case supervision and 300 hours of individual analysis. The requirements of individual institutions often exceed NAAP requirements [30].

In addition to the ethical guidelines of each clinician's discipline, the IASD requires that dream work practitioners recognize the dignity and integrity of the dreamer. The dreamer is the decision-maker regarding the significance of the dream and may or may not share any part of the dream he or she chooses. The hour belongs to the patient; therefore, the patient's lead supersedes the clinician's interest. Ethical dream work guides the dreamer to more fully experience, appreciate, and understand the dream. It also recognizes the validity of approaches from many traditions and cultures [31].

The patient-therapist relationship is the essential treatment tool in psychoanalysis. The analyst listens with an uncommon empathy, a situation in which the analyst's own unconscious engages as a "third ear." Personal analysis prepares the analyst for this work in three ways. First, the analyst learns analytic technique by experiencing the methods as a patient. Second, knowledge of personal idiosyncrasies and blind spots arms the analyst against overlooking or exaggerating those of his or her clients. Finally, and most importantly, even when bombarded by the strong feelings expressed by clients, the analyst avoids reacting with personal feelings (whether conscious or unconscious) and abstains from meeting personal emotional needs, which the patient's behavior may stimulate. The analyst's focus at all times is to help the patient observe self-behavior.

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].

Culture plays an integral part in how an individual interprets dreams and how much significance is placed on the dream [36]. When analyzing a patient's dream, the psychoanalyst should understand that interpretation can be affected by the patient's motivation to extend pre-existing beliefs or ideas or to enhance existing attitudes. Although dreaming occurs in all cultures, each individual will respond differently to the act of dreaming and the interpretation of dreams; cultural variations in the narrative content will exist. The psychoanalyst should be aware of the patient's cultural assumptions and should set aside judgmental biases in order to obtain a nonbiased assessment [42]. Assessing and interpreting dreams should be an open, communicative process between the analyst and the dreamer [43].

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].

Those who study their own dreams are in good company. Both Freud and Jung recorded and studied their dreams, a practice continued by contemporary experts. Dream study can be done alone, but therapists often see concerns or painful connections otherwise missed. Dream recall can usually be established and improved simply with conscious intent. Using a notebook or other record upon waking (even if only a few images are recalled at first) can help to recapture the dream.

Freud chose to demonstrate his methods with analysis of his own dreams. He set out to articulate psychologic processes that characterize normal development and functioning. He had analyzed thousands of clients' dreams at the time he wrote The Interpretation of Dreams, but they were all potentially attributed to clients' pathologies. Freud recorded many of his own dreams, so he had data from a healthy source. Freud's example of self-study is a model for clinicians. Anyone hoping to help others understand dreams should start with their own.

Some clients spontaneously offer dreams; others do not, which may indicate that they devalue their internal lives, including dreams. Questions asked early in treatment, including inquiry about recurrent dreams, memorable childhood dreams, and recent dreams, can signal their importance [50]. Freud's instructions were simple and direct: consider the dream's circumstances, suspend self-criticism, and report all thoughts associated with dream elements. Dream work gains may include: the production of new material, including memories, associations, fears, and conflicts; opportunities for empathy, respect, and collaboration (i.e., advances in the therapeutic alliance); and opportunities to engage the patient's resources in problem solving, thereby increasing self-observation, insight, and ego strength. All of these are therapeutic goals shared by most forms of psychotherapy.

Freud's analysis of the Irma dream can be intimidating. However, his recommendations for clinicians just beginning dream interpretation can mitigate concern [31]: