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Malaysian Journal of Medical Sciences , Vol. 16, No. 4, Oct-Dec, 2009 pp. 42-49 SPECIAL COMMUNICATION Dreams in Jungian Psychology: the use of Dreams as an Instrument For Research, Diagnosis and Treatment of Social Phobia Siamak Khodarahimi Islamic Azad University-Eghlid Branch, Eghlid, Fars Province, Iran Submitted: 21 Apr 2009 Code Number: mj09032 Abstract Background: The significance of dreams has been explained in psychoanalysis, depth psychology and gestalt therapy. There are many guidelines in analytic psychology for dream interpretation and integration in clinical practice. The present study, based on the Jungian analytic model, incorporated dreams as an instrument for assessment of aetiology, the psychotherapy process and the outcome of treatment for social phobia within a clinical case study. Keywords: dream, jungian approach, social phobia, psychotherapy, medical sciences Introduction Dreams have been traced in mankind civilisation, and Aeppli (1955) noted the dreams are a quite personal aspect of human experiences (1). Freud’s pioneering work on the interpretation of dreams extended our knowledge of dreams as a part of clinical practice in psychology (2). Historically, the significance of dreams for clinical interpretation has been considered by psychoanalysis, analytical psychology and gestalt therapy approaches. There are many guidelines in analytic psychology that help therapists to integrate a basic approach to dream interpretation into clinical practice. There are various viewpoints on dream emergence, importance and interpretation in the disciplines of literature, religion, medicine, sociology and psychology (3). As Jung cited, one would do well to treat every dream as though it was a completely unknown project, look at it from all sides, take it in one’s hand, carry it around, and let one’s imagination play around with it (4). Theoretical and Research Bases The present article is primarily based on Jung’s seminal work, which has been clarified and extended through years of clinical investigation by Hall (5), Whitmont (6) and Whitmont and Perera (7) on the exploration of dreams in the aetiology of mental disorders and psychotherapy prognosis. Guided by a therapist, clients must come to grips with powerful, unconscious archetypical complexes that are in constant and submerged flux. The archetypes of the shadow and the anima-animus are two domains of the principal oppositional and tumultuous unconscious forces that must be reconciled. The therapeutic modality that is most commonly used to bring these and other archetypes to conscious awareness is dream work. Analytical psychotherapy attempts to create a communicative link between the conscious and unconscious and make the unconscious understandable through dialogue, association and interpretation of what may appear to the individual to be quite illogical and completely undecipherable (8). Based on analytical psychology, the goal of a treatment program is to incorporate and clarify the role of dreams as an instrument for the assessment of aetiology, psychotherapy process and treatment outcome in social phobia. Dreams have two major implications in clinical practice, exploration of the aetiology of mental illness and the resulting therapy trend and outcome. From an aetiological point of view, dreams focus on the important unprocessed mental and emotional issues of the day or during the life span; thus, dream work can quickly bring the most important issues that a person is dealing with on a subconscious level to consciousness. On the other hand, dream work without therapy is not necessarily effective in reducing the emotional and mental disorders that may surface. Dreams process current situations that trigger these mental disturbances and then attempt to reverse the underlying fears and misconceptions through a process called “compensation” (9). Jung observed that dreams are driven by a natural tendency to bring resolution and closure to unfinished emotional and mental problems of the day (10,11,6). When we sleep and dream, episodic memory is disconnected; therefore, we cannot recall the specific event, but the emotional context of that event, if unresolved, comes to the surface to be processed. Those emotions arouse early threat reactions as well as underlying fears and misconceptions that have become part of our internal model of reality in our belief systems. External events that do not fit that internal model become new threats to the model (9). The dream not only illuminates the current issue or threat, but tries to accommodate it by finding a “fit” between the current experience and our internal model. When the internal model is corrupted by old fears and misconceptions, dreams illuminate those barriers and “compensate” by projecting adjustments in order to achieve a “fit” (2,6,9,10,11,12,13). Consistent with natural and necessary expressions of life force, dreams provide access into unconscious areas of life. They convey specific and appropriately timed messages that can assist the dreamer with problem-solving, artistic inspiration, psychological development and spiritual deepening, and they are important for healing (7). Through dreams, a patient’s inner aetiology of mental disorder and his or her reaction to psychotherapy may be expressed as symbols, metaphors, analogies and stories that are rooted in personal and collective levels of unconsciousness. From the therapeutic point of view, the metaphors and analogies are somewhat obvious, but this is not the case with all dreams. Every dream reveals information about the dreamer’s psychological and physical dynamics and spiritual process. Dreams also touch upon relationship issues projected from past, problematic in present or newly emerging situations. Hereby, dreams facilitate the working through of old patterns that impede relationships. Dreams may be about the therapist, others, life’s work and need gratification, the unconsciousness, or the Self. Whitmont and Perera (7) discussed the roles of dreams for the reality of the therapist, transference reactions, inner therapist, countertransference dynamics, the process of therapy, and the therapist’s dreams about the patient comprehensively. To better understand the patient’s dreams for psychotherapy, one should take note of the dream language. The “language” of the dreaming mind is unique; it is how the dreaming brain communicates, and the information being processed is predominantly represented by association, symbol, metaphor and visual imagery (6,9,10,11,12,13). Dreams communicate using image combinations, just as we communicate with word combinations in waking life. Dreams are similar to garlic, which may smell unpleasant but is quite effective for our health. Dreams may be unfavourable in appearance but understanding their latent messages facilitates the healing of individuals’ mental health issues and personality enhancement. The mystery of dreams for human mental health accomplishment is more obvious when combined with Jung’s notion about human nature. Jungians view humans in a positive sense and believe that they are inherently predisposed to make their individual mark in the world. This individuation process is not accomplished by merely obtaining fame and glory through material achievement or notoriety (14). In fact, dream exploration is a means for individuation and actualisation attainment. Dreams act as the purest form from which to draw on the vast storehouse of the unconscious, and often emerge as the most fruitful source of therapeutic material. Dream work is a fundamental core of analytical therapy (15,16). Despite the importance of dreams for mental illness diagnosis, there is little evidence for their application in the prediction of psychotherapy outcome, and few useful guidelines for the clinical interpretation of a patient’s dreams. Case Presentation I would like to present a brief description from my work as the therapist for Lida (a pseudonym). Her treatment was free-of-charge since it was carried out in a community-based Psychological Outpatient Clinic in Ferdowsi University of Meshed, Iran, that offers services to the city inhabitants and outpatients. Treatments are provided to potential patients as brief therapies that are suitable for consultations emerging from their life events or critical situations. Patients assessed initially by a psychoanalyst and a clinical psychologist (who is a supervisor rather than a therapist) for the adequacy of the type of treatment offered for their particular condition and are then provided psychotherapy or referred to a different treatment facility. Presenting Complaints The problems that Lida presented were social phobia and public fears. No concerns about mood, other anxiety disorders, or other symptomatology were expressed by Lida or her family and friends. She reported increasing anxiety and worry that included physiological, cognitive, and behavioural symptoms during the course of each semester as classes approached. When I first began to work with Lida, a 22-year-old university student, she was quite anxious and was diagnosed with social phobia based on the DSM-IV. She avoids public talking and her academic performance during the past two semesters particularly declined. Her social phobia is sometimes accompanied by transit panic and depressive symptoms but there was no evidence for a comorbidity disorder. Her problem began in adolescence and increased with entrance to university. She was reared in a family with a history of maladjustment behaviours and did not experience trustful and calm relationships with her parents. She is more avoidant of men than women. Her father was quite rebellious, over demanding and advising alike a clergy, which generally frustrated her. Lida believed femininity to be inferior and was more interested in masculine roles. She did not have satisfactory relationships with women, including her mother. She underestimated the significance of her feminine needs and showed little interest in and a hostile approach to femininity, except seductive behaviours for capturing men. She participated in 30 therapeutic sessions using the Jungian approach. Assessment Lida’s fitness for psychotherapy was evaluated the basis of the DSM-IV diagnosis criteria in the patient sample (17). The presence of subclinical personality disorder features or traits was also recorded and ruled out. Commensurate with university-based samples, the community outpatients in our clinic primarily experienced psychological disorders with a mild to moderate range of severity. This mild to moderate range of impairment was evidenced within the DSM-IV diagnostic categories, clinician rating scales, and self-report measures. Similarly, each patient provided written informed consent to be included in the research program. Case Conceptualisation There are more words written on the subject of dreams and their function from a wide variety of different perspectives than on any other subject within depth psychology. This is true for both psychoanalysis and analytical psychology. We know that dreams reflect personal ego strength and know a good deal about how to define dreams, dreams’ mechanisms and their myths and symbols in analytic psychology and psychoanalysis; however, there is lack of evidence on their role in psychological aetiology and their contribution to the prediction of psychotherapy outcome and patient prognosis. As Jung noted, a dream never expresses itself in a logically abstract way but always in the language of parable or simile, which is a characteristic feature of primitive language (18). We agree with Whitmont and Perera (7), who noted that images, symbols, allegories, and rebuses are the main languages of dreams in clinical practice. Since dreams operate in an altered state of consciousness, they are a primary process that is beyond of man rational categories for space and time and they integrate potent materials from past, present and future. This information may even come from archetypal levels with which the dreamer is quite unfamiliar. Our perception of dreams may be visual, auditory, proprioceptive or kinesthetic. Such images are also apparent in ancient and sacred pictographic writings. Allegorical aspects of a dream describe objective, or outer, and subjective, or inner, situations that are to be brought to the dreamer’s psychological attention. Allegorical refers to rationally understandable facts and psychological dynamics that have been ignored or have been out of reach of the consciousness. Symbols shows what can be seen only through a glass darkly. In Jung’s definition, a symbol is the best description or formula of a relatively unknown fact that is none the less organised or postulated as existing (19). Symbols point to existential or ever superpersonal significance as a basic concern of psychic life. They also express the need for meaning in life that is beyond sensation and instincts. All products of the unconscious that come to awareness have similar functions as symbolic messages. Archetypes are the birthing agents of symbols and these symbols are commonly found in dreams. Dreams are the avenue of egress for the unconscious to gain awareness, and are the axis on which psychotherapy revolves. Jung’s symbols are different from Freud’s symbols. For Jung, symbols are intuitive ideas that have not yet formed, as opposed to Freud’s view that symbols are symptomatic signs released into conscious awareness (18). Finally, a rebus is a representation of a phrase by pictures. These pictures might more or less clearly suggest syllables words or ideas. Hence, the most important aspect of dream work in analytical psychology is its interpretation, which, according to the Jungian conceptualisation, involves three steps in clinical practice (3). In the first step, the dreamer writes the details of the dreams as quickly as possible after awakening (15). This provides a clear understanding of the exact details of the dreams before the memory of the specifics becomes convoluted, commingled or distorted. In writing the dream content in specific detail, the client attempts to describe and clarify the context of the dreams. Context specification is important because it keeps the therapist from injecting premature associations and attempting to interpret the dreams too early. In this first step, the therapist questions the client incisively to ensure that both client and therapist understand the exact content; sequence of dream events; dreamer’s feelings about dream images; whether the dream is a repetition of a previous dream or is one in a series of dreams; and the power, strength, or valence of the dream. A series of dreams allows greater confidence in the interpretations than does one isolated dream. A series of dreams provides a clearer perspective of basic or developing themes (15). The more powerful the dream, the more important the message the dream is attempting to reveal to the dreamer’s conscious ego and psychic system. In the second step, the dream is reassembled with amplifications in mind. The gathering of associations and amplifications in progressive order on one or more of three levels, which include personal, cultural, and archetypal segments, helps to identify the core maxims of the dream images (3). Amplification of a dream is analogous to “peeling” the three layers of a complex: personal associations; images of a more cultural or transpersonal nature; and the archetypal level of amplification (20). In many dreams, the order of events holds much of the secret of the dream. Questions are open-ended and do not focus on the specific questions found in step one. Rather, amplifying questions help the client to discover the larger picture and set the stage for expanded understanding of the dream. Therapist questions during the reassembly/amplification step could include: “What do you think the dream wants to tell you?”, “How do you see the dream now?”, and “How do you feel about the dream?” To further amplify the dream, the therapist may use a fairy tale or anecdote that parallels or explains something related to it. Amplification does not involve interpretation but rather adds information to the client’s story or reframes it. The purpose of this step is to help the client recognise similarities between his or her personal experience and its archetypal configuration (21). Finally, in the third step (or the assimilation phase), the therapist and the client make conscious sense of the dream (3). An important aspect of the third step is for the client to come to the point where he or she can answer the therapist’s questions regarding dreams conscious attitude against the dream compensation and dreams symbolic attitude in the client’s unconscious world (15). In a new paradigm, James and Gilliland (22) specified these steps in written details, reassembly with amplification and assimilation respectively. We suggest that dream interpretation and analysis may be particularly useful in treating social phobia, in which the phobic origins are unconscious and imaginary, such as infantile trauma or archetypal themes. In this context, the present case study describes the use of dreams analysis to treat a female youth with social phobia. The case also highlights the utility of dream as an instrument for diagnosis, aetiology and intervention in clinical psychotherapy. Analytical therapy typically involves four stages of treatment: confession and catharsis, elucidation, education, and transformation. While each stage seems final and may be sufficient for a return to mental health, none is complete in itself. Even transformation is not an endpoint (18). The treatment provided focuses on the patient’s chief complaint and its underlying core conflict. Psychotherapy is guided by explicit goals that the patient and therapist discuss and agree to work upon. In the present study, we used dream interpretation as the foundation of our exploration of Jungian therapy. We assessed patient improvement from pre- to post- treatment with the Comparative psychotherapy process scale (CPPS). The CPPS is a measure of psychotherapy process that is designed to assess therapist activity, process variables, and psychotherapy techniques used during the therapeutic hour (23). The scale consists of 20 items rated on a 7-point Likert Scale ranging from 0 (“not at all characteristic”), 2 (“somewhat characteristic”), 4 (“characteristic”), through 6 (“extremely characteristic”). The CPPS may be completed by the patient, the therapist, and/or an external rater. One unique feature of the items on the CPPS is that they were derived from empirical studies that compared and contrasted Psychodynamic-Interpersonal and Cognitive-Behavioural oriented approaches to treatment. This scale consists of two subscales: a Psychodynamic-Interpersonal subscale (PI; 10 items) and a Cognitive-Behavioural subscale (CB; 10 items). The PI subscale measures therapist and patient activity found in empirical research to be emphasised significantly more in a Psychodynamic-Interpersonal oriented treatment than in a CB treatment. Items include
Likewise, the CB subscale consists of items that are significantly more characteristic of Cognitive-Behavioural oriented therapy. Items include
Coefficient Alpha for the PI and CB subscales (N=101 rated sessions) are both reported as 0.93 (23). Therapy outcomes for the present case were evaluated from two perspectives: patient self-report of social functioning (work, family, and leisure) and therapist ratings on CPPS. In the present study, patient improvement and functioning was assessed during pre- and post- treatment intervals via CPPS by herself, her family, her classmate and the therapist. Course of Treatment and Assessment of Progress We primarily evaluated Lida’s series of dreams for exploration of her social phobia aetiology and prognosis of psychotherapy outcome. Her first dream in the initial phase of psychotherapy was as follows: “My friend and I are sitting in a window that was like the one in our school at university, but my friend seems calm and confident and I fear falling down.” We know that the earth is a symbol for femininity in depth psychology while the issue of femininity is embarrassing for Lida due to earlier disadvantaged experiences. Therefore, fear of falling into the earth in the above dream directly adheres to her core aetiology and basic problem for identity attainment. She has a latent and unconscious paradox toward the femininemasculinity spectrum that primarily originated in her personal unconscious experiences from infancy to adolescence. It is apparent that she is dissatisfied with her feminine self in comparison to other females. This assumption was supported by the associations and dream clarification of her dream. Psychoanalytically, her dream adhered to identification abnormality in early childhood and psychosexual development. Her associations mostly confirmed the feminine nature of the earth symbol rather than a fear of failure in university tasks. This dream highlighted the nodal aetiology and future orientation of her psychotherapy, and dream helped her to follow her confession and catharsis. The dream served as a “guideline for the direction of therapy” and “a prediction of the outcome” in the Jungian sense that most dreams have a forward-looking momentum, a prospective dimension. Therefore, her analytical therapy focused on childhood traumas that explain her phobia, especially sexual abuse at the hands of her brother. These associations helped her to overcome childhood maltreatments and to develop a new attitude toward her masculine and feminine archetypes. Now, we note her dream message after several sessions. Her second dream, in the middle phase of psychotherapy, was as follows: “I am returning from cemetery and going to my uncle’s house, and I have a big dark covering on over of my head. There is no one on the street. I sense someone following me, turn back, and see a male following me. I don’t acknowledge him, but I walk more and more quickly and he does as well. I enter a place in row and it is raining, and the big dark cover on over my head is completely wet. I feel the male who is following me wants to hang me. I run and he chases me, but something stops me. I push open a door to run away, but he gets me and begins to strangle me. I think he is the angel of death.” This is a type of combined imagery that portrays her attempt to run from her inner world of silence, aloneness and social avoidance to a prosocial world. The cemetery and dark cover on her head may address innate hopelessness and rigid mental imaginations that severely distressed her. She attempts to change these feelings and also fears from this alteration. Her associations to the uncle showed that he is likeable, rational, religious, flexible, and responsible man who compensates for her father’s irresponsibility. The uncle association increases her hope, peace and faith. Furthermore, it shows her tendency for change, which was inhibited by masculine ideas and negative experiences with men in the form of abuse. The present imagery indicates her inner struggle to overcome psychotherapy obstacles that originated in the personal unconscious level. As aforesaid, the clinical interview confirmed a history of abuse by close relatives such as her brother and that escaping from he was not possible. Dream clarification and perception of its emotional amplification with free recall of the above traumatic experiences during sessions primarily helped her in terms of emotional catharsis and stabilisation, and then she moved toward the transpersonal or collective unconscious level. For example, the uncle and rain may highlight the transpersonal levels of masculine and redemption archetypes. The dream served as a “guideline for the direction of therapy” and “a prediction of the outcome” in the Jungian sense. Here, psychotherapy focused on her detailed childhood self-disclosure and attempt to develop more efficient self-protective social skills. The present dream serves as a good means for elucidation and educational goals in treatment. Her third dream, in final phase of psychotherapy, was as follows: “I am in an unfamiliar house. An animal like a cat wants to get our chickens, and I am running to get away from it while it attacks me. When it approaches me, I break its back, and the people beside me call for me to try again, until I finally capture it.” In depth psychology, unfamiliar home is an allegory for foreign departments of the intrapsychic world. Her dream shows new insights for the exploration of unconsciousness boundaries in her personality, especially for anima. She attempted to kill a cat, which may indicate her tendency to control her undesirable manners such as anger, hostility and ill-will in the animus and persona sectors. It guides psychotherapy toward necessity of patient balance in introversion-extraversion spectrum because she was only noticed to people beside her rather than her innate world. Dream was addressed to her shadow, anima and animus for a logical balance in her four psychological functioning and their usefulness for her transformation during the psychotherapy. During dream clarification and interpretation, we discussed all of these archetypes in the therapeutic sessions. This dream operated as a prospective dimension for her psychotherapy. For instance, she was very seductive and had many mysterious sexual impressions and evil-like behaviours toward males in interpersonal relationships that resulting in a context for her abuse. Similarly, she was inattentive to her thoughts, sensations, feeling and intuitions. Otherwise, she primarily followed the masculine stereotypes. This prospective insight helped Lida to monitor seductive behaviours, which threaten her security in social contexts, diminish her animus orientations, and balance her main psychological functioning. Her fourth dream, in the final phase of psychotherapy, was as follows: “I am in an exam session and a female is that the instructor of the course. She sits in front of me and notices that I am somewhat afraid. As I begin to answer, I see a coin with the word DOCTOR on its surface, but on its other side is written “myself”. When I encounter a problem, I immediately look at it to find out “what to do”. This dream involves a symbol that is directive and healing for the patient. Furthermore, it expresses her congruency with feminine nature, sense of internal empowerment and search for meaning with feelings of internal comfort and self-faith. The dream also suggested that the psychotherapy could be terminated. It indicates her transformation, improvement and cure outcome in the reality world that is correspondent to her improvements within external environment. Based on her associations, recordings and homeworks of the four psychic functions, dream clarification and interpretation confirmed the above assumptions. The present dream functioned as “inner healing symbol” exploration in the Jungian sense. It demonstrates a forward-looking momentum for the patient and guides her toward self fulfilment of everyday problem solving tasks as well as the end of treatment. Conclusions and recommendations to clinicians According to the case assessment during pre- and post-treatment intervals via CPPS by herself, her family, her classmate and therapist, she improved significantly. Analytically, the present essay indicated that rebellion originated in animus and childhood maltreatments, and manifested itself in dreams as male figures in female with social phobia. Childhood and infantile traumatic events, psychosexual development malfunctions, and inefficient coping skills for solving current life events may express themselves as features in a patient’s dreams (24,25,26). Dreams as a core regulator of the life force can help patients achieve a balance of anima, animus, persona and shadow archetypes of personality, which is beneficial for a therapist’s psychotherapy prognosis (3,27). As Jung (15,18) noted, dream work is a fundamental core of analytical psychotherapy. Dreams can reflect patients’ psychological and physiological needs and prognosis or outcome of psychotherapy. Khodarahimi (3) pointed out that the patient’s dreams have direct implications for the aetiology of the illness and psychotherapy outcome and prognosis. Dreams’ clinical workings tend to divulge to actual reality of the therapist. It exemplifies the transference reactions, the inner therapist, the countertransference dynamics, the process of therapy, and the therapist’s dreams about the patient. Dream is an instrument for diagnosis, research and treatment of mental disturbances in a clinical setting. In conclusion, the present findings support Jung’s notions of dream significance and its application in four stages of treatment (15,16). However, the present findings are limited as they are from a case study on social phobia. Further research should examine dream roles in aetiology, prognosis and treatment of other psychological disorders at both individual and collective levels in inpatients and outpatients within diverse cultural contexts. References
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