The Medical Humanities and the Clinical Use of Dreams
The Dream as an Introspective Tool
Dreams and Dream Visions have been used as a conceptual vehicle for literary, artistic, musical, political, scientific and religious points of departure. The clinical use of dreams in Western civilization dates back to the ancient Greeks. Heraclitus was the first philosopher to teach that dreams were not induced by the Gods, instead were personal creations. Hippocrates who is referred to as the "father of medicine" and a contemporary of the philosopher Socrates used the dream as a medical diagnostic and therapeutic tool for curing illness. Hippocrates taught that dreams reflected a person's health or illness.
The modern clinical use of dreams was pioneered by Sigmund Freud Interpretation of Dreams who rekindled the ancient art of interpreting dreams and helped to develop many concepts of psychodynamic psychotherapy. The dream which had also served to institutionalize the Cartesian scientific revolution in the 17th century was a philosophical analytical tool perfectly created for the modern scientific and medical experience. As part of the medical humanities dream analysis of dream work provides insight into the nature of the human condition. In this sense, the dream offers us medical tools and methods to examine and understand the everyday psychodynamics of humanity. Dreams provide a therapeutic guide through the darkness on the poetic journey to the light.
As an endoscopic tool, much like a microscope the dream text provides insight into hidden psychological processes. This introspective instrument allows access to the psychodynamics of individuals and speech communities. As the archetypal literary critic Northrop Frye informs us, the concepts of nature and culture as they relate to literature are not imitations of the world but express the dream of being human. In dreams we gain access to understanding the problems of society, its nature, origins, and the creation of meaning and reality. Frye proposed a total "order of words" in which literature "imitates the total dream of man," structured by literary archetypes. The dream explores this constructed literary universe of Dream Vision a dream world created by the total archetypal energies of humanity.
Poetics of Growth -or- Metaphors We Live By
In order to understand the total dream work of humanity, we can employ the ideas found in the field of research known as semiotics which is the study of the communication process of sign and symbol making in individuals and communities. The concepts of the semiotics of poetry can be applied to understanding the fundamental nature of dream work. George Lakoff and Mark Johnson Metaphors We Live By believe that our conceptual systems are structured by metaphors, these conceptual metaphors are the driving force of thought, language and literature. Support for this notion was reinforced by Howard Pollio's (et al) Psychology and the Poetics of Growth: Figurative Language in Psychology, Psychotherapy and Education whose study informs us that on the average, speakers of the English language use 3000 metaphors and 7000 idioms per week. The mythopoetic aspects of all signs, symbols and symptoms fuel the idiomatic imagination and dream work of the individual and the community.
Diagnostic and Therapeutic Value of Dreams
David Gordon Therapeutic Metaphor: Helping Others Through The Looking Glass sees metaphor as the foundation of all story telling. Gordon believes that fables, anecdotes and idioms all convey a message that instructs the individual about learning to understand a problem. Citing Sheldon Kopp's Guru: Metaphors from a Psychotherapist Gordon believes that therapeutic skills involve the ability to formulate and use therapeutic metaphors. For Gordon, "Each therapy or system of psychology, then has as one of its basic constituents a set of metaphors (in form of a vocabulary) which for some individuals is capable of conveying some measure of what their experience of the world is like."
Freud had already discovered in his medical case study of Dora (aka Ida Bauer) that she was suffering from a "fine poetic conflict". Yet Dora would not follow Freud's poetic licence in his emphasis and interpretations about her sexuality. In fact, what Freud failed to realize and diagnose was the true poetic meaning of Dora's dreams, namely that Dora was concerned about her femininity and felt herself restricted and oppressed as a woman by the dominant patriarchal poetic definitions of womanhood and marriage. Dora was the classic example of what the feminists Gilbert and Gubar have metaphorically termed The Madwoman in the Attic.
The medical diagnostic value of dreams continues to be underutilized in our culture. If you go to most bookstores you will most likely find the topic of dreams in the New Age section. As part of the modern canon of medicine the dream remains an esoteric oddity. Despite the skepticism, we can find psychiatrists, psychologists, psychotherapists, social workers, marriage and family counselors and other mental health professionals currently working with dreams. The Diagnostic Statistical Manual (DSM IV), the International Statistical Classification of Diseases (ICD-10) and the Psychodynamic Diagnostic Manual all provide clinical diagnostic frameworks to understand cognitive, emotional, social and psychosomatic signs and symptomatic patterns.
Know Thyself -or- The Clinical Use of Dreams
Deirdre Barrett Trauma and Dreams presents a collection of essays which investigates the effects of trauma on children and adults. Kelly Bulkeley Dreams of Healing: Transforming Nightmares into Visions of Hope is a book which was written in the aftermath of September 11, 2001 and explores the individual and collective nature of post-traumatic nightmares and the mysteries of healing. Anne Sayre Wiseman Nightmare Help: a guide for parents and teachers provides tools to map the problems and conflicts of anxiety provoking dreams onto a "paper-stage". As a form of art ("dreams are the artist at work at night.") and play therapy the intent is not "dream analysis", "nor psychoanalysis", instead "to approach the dream story as a problem to be solved in a way that the dreamer finds useful so they learn more about themselves."
To know thyself is the ability to read, write, and speak about experiences, imaginings, dreams and memories. The philosopher Gaston Bachelard leads us to believe that better dreaming is the key poetic ingredient to better reading, writing and speaking. Dreams open the gates of the mind to analysis. In the theatre of the sleeping mind, a seeming jumble of images, thoughts, feelings and sensations derived from the remembrances of the waking world flashes across all our individual and collective dream screens on a nightly basis. This ritual communication process of dream work presents us with the raw and visceral nature of life and the human condition.
Far too few books have been written and/or published about the use of dreams in psychotherapy. Exceptions include such books as Joseph Natterson's (ed) The Dream in Clinical Practice which brings together a variety of essays designed to enhance the diagnostic and psychotherapeutic use of dreams. Thomas M. French and Erika Fromm Dream Interpretation: A New Approach develops a focal conflict theory of dreaming. French and Fromm believe that maladaptive defense mechanism responses are developed when dealing with cognitive-emotive conflicts, these defense mechanisms become the primary cause of symptomatic thought, affect and behaviour.
Ernest Lawrence Rossi Dreams and the Growth of Personality: Expanding Awareness in Psychotherapy believes that personal growth and creativity are primary dimensions of psychotherapy and a recipe for positive psychological change. Dreams underscore developmental symptoms which are principally caused by blocked growth and failed expansion of awareness. Psychotherapy is aimed at undoing the phenomenological damage and facilitate personal growth. Montague Ullman and Claire Limmer (eds) The Variety of Dream Experience present a collection of essays which include the training of therapists in using dreams for the purpose of treatment in clinical practice.
Case Study: A Symptom Reading of Dreams
The modern literary genre, of the ‘case study,' purports to be a retrospective (anamnesis) analysis of the signs and symptoms of illness in which the physician is the detective and the patient is the traumatized victim. Freud believed that medically healing psychological trauma, wounds and injuries inflicted to the mind was imperative for social and cultural mental health. Several authorities have touched on the neglected factor of how dreams can provide a medical framework for the healing power of our nightly visions. Marc Ian Barasch in Healing Dreams points out the "diagnostic power of dreams" in anticipating medical problems. Robert H. Hopcke in Men's Dreams, Men's Healing notes that the search for wholeness is a masculine theme. Hopcke uses a Jungian frame to understand the myths (poetics) patriarchy and heal the wounds of masculinity. Patricia Garfield in The Healing Power of Dreams believes that dreams "can help to keep you healthy", "warn you when you are at risk", "suggest treatment", "and signal your return to wellness". "All you have to do is listen and learn."
A symptom reading of dreams uncovers the buried conflicts hidden in the reported dream text. We generally cannot treat symptoms, instead we are compelled to treat causes such as those induced by traumatic experiences which contribute to many psychological problems such as personality disorders. Up until the turn of the 20th century, "trauma" was referred to as an injury inflicted on the body. Freud changed the meaning of the word: it became extended to a wound inflicted on the mind. We have come to learn that war, rape, child abuse, armed robbery, auto and industrial accidents or poverty can precipitate post-traumatic stress disorder (PTSD). The nightmares that relive traumas are invariably part of the clinical picture. The collective nightmare represents the polyphonic voices and screams of the walking wounded.
Many symptoms found in dream are stress related. Louis Breger The Effect of Stress on Dreams shows that stress influences the content of dreams providing further support to the pioneer of stress research Hans Selye's The Stress of Life discovery of the medical basis of the wear and tear on the mind and body. The perennial problems and nightmares of hate, terrorism, prejudice, crime, abuse, divorce, stigmatization are all part of a much larger list of problems of the dark (noir) side of the human condition found in our dreams. Working through these problems is a central goal of the work of psychodynamic psychotherapy.
Life Writing and the Reliable Narrator
Dreams and dream work are archetypal forms of enacted creative writing providing each individual with the possibility of developing their own poetic frame story of their being. Viewed in this light, the dream becomes an autobiographical theatre, where a life story is imagined, envisioned, remembered and acted out on our inner stage of our being. The life writing questions that become acted on are; Where do I come from? Who am I? Where do I want to go? Who do I want to become? How can I express myself? What do I want to achieve? A developmental ontological itinerary can be imagined and viewed. We are able to imagine and see the longitudinal dream research study perspective of one's dreams stretching from childhood until death. Patricia Garfield's Women's Bodies Women's Dreams is an attempt at such a longitudinal study.
If life imitates art, then dream work uses words and images to conceptually shape the artistic material, transforming word and image into a work of art. If the arts imitate life, then the artistic material it uses is derived from the total dream work of humanity. The total dream work of humanity employs literary techniques for the purpose of telling a story, the dream being the most archetypal of stories. Most dreams use the literary technique of the first person narrative which is spoken and told by one character. The first person narrator who refers to him or herself by using the word "I", is a voyeur, an exhibitionist, a demonstrator of life's artistic capital.
The first person narrative is used in psychotherapy so that narrator and the reader can solve the case together. One problem with the first person narrator is that their stories are often found to be unreliable. The story is then viewed through the eyes of the narrator who may not always be a reliable guide to follow. In Jane Austin's Pride and Prejudice we never enter the consciousness of the other characters in the novel we only know them through Elisabeth's interpretations which are often found to be inaccurate. We come to realize there may be a gap or disconnect between the conscious narrator and author of the story, who as it relates to dreams is paradoxically looked at as being one and the same person.
The unreliable narrator may be one whose lens and optics of the world and reality suffers from cognitive biases, interpretive distortions or consciously perceives the world from the perspective of a variety of fallacies and illusions. Dreams reported in the clinical practice illuminate life stories which are often subjectively riddled with stock character flaws, insincerity, lying, self-deception, prejudice, excuse making, poetic repetition compulsions whose ritual need is to reenact, rework and rewrite the story of psychological conflicts and injuries that they have suffered. In the words of the popular TV character Dr Gregory House "everybody lies". The dream as a lie detector is the great equalizer.
The Healing Power of Dreams
Carl Gustav Jung had already realized that dreams could be read and analysed on both subject and object levels. When the subject becomes object, self-analysis and introspective self-knowledge becomes a conceptual possibility. The dream provides an objective means to close the subjective gap, to reconnect that which was lost, that which was forgotten and unrecognized. The dream allows consciousness to find and develop a new point of view and perspective of life and being.
The dream analyst uses the dream text as a point of departure to arrive at therapeutic narrative meaning and understanding for the purpose of treatment. The healing powers of dreams have a proven record. The Jungian psychologist C.A. Meier Healing Dream and Ritual finds the ancient Greek myth of the power of oneiric healing still operating in modern humans. The dream is a medicine or pharmakon. The prescription to our ills is found in our dreams, and its incubation can be found in the ancient works of the Iliad and the Aeneid. The Asclepius cult presented the healing aspects of the medical arts and sciences. The panacea of oneiric healing included hygiene and cleanliness, and testify to the power of dreams. Indeed, the Hippocratic Oath ordains that doctors should first do no harm. Drugs are seen to have paradoxical effects in that they deliverer poison and therefore death, or medicine and life. The right dreams were incubated in temples, which in turn led to the pharmakon and a cure.
Working with dreams in my private clinical practice, has enabled me to gain invaluable access and insights into the unique narrative conflicts and problems that my clients are faced and coping with. The dream has allowed me to find diagnostic, and therapeutic strategies and methods. When working with dreams, I have no therapeutic metaphoric ideology such as the Freudian, Jungian or Adlerian frames, instead I try to let the dream and the dreamer's dramatic voice speak in its' own poetic language and narrative of Self.
One of my first private practice clients was a man who reported suffering from a variety of symptoms. The client's presentation and diagnosis were substantiated by the reporting of his dreams, which indicated that he was suffering from agora- and social phobia. While the client was never fully cured, he was able to build a broader and more satisfying "comfort zone". An incest survivor's dreams gave me much needed therapeutic information and a warning. The dreams told me if I pushed the client to hard she would suffer a psychotic break. A client with three children who was dealing with depression disclosed her dreams to me and to my surprise what I found was a child that had been aborted 12 years earlier still living in her mind. The client with her husband was able to do the necessary grief work and lay the child to rest. More exotic clinical cases included a client with MPD, one with Aspergers and one that dealt with Munchhausen by Proxy.
A case that I call my "fatal cure" had a young girl 13 years of age referred to me for "panic attacks". The parents had informed me that everything at home was fine. The panic attacks apparently had no rhyme and no reason. The dreams were also somewhat unclear as to the cause, until in one dream the young girl presented she had the family conspicuously going on vacation for some unknown reason. The focal point of attention in the dream was on the mother, who I then re-interviewed and she disclosed that she had been having an affair. The mother had decided that she was staying in the marriage until her daughter was a few years older. She did not want to reconcile the marriage. The mother disclosed her dilemma to the family and moved out of the family home. Of course, what happened to the panic attacks of the daughter? They disappeared, the therapy cured the panic attacks, however the disclosure was fatal to the family, thus the "fatal cure".
The Philosopher Physician and Therapeutic Metaphor
The dream of the philosopher Friedrich Nietzsche that a group of revolutionary philosopher physicians on the planet would muster a mobile army of therapeutic metaphor and rid the social fabric of humanity from all psychopathology has gone unrealised. Do national and International health institutions such as the Center for Disease Control and Prevention in the United States or Health Canada or the World Health Organization pay attention to the healthy or unhealthy dreams of their citizens? The political rhetoric that they promote health and safety is superficial as long as the vital dimension of dreams is not covered. Health is a psychosomatic whole in which dreams and dreaming play a vital role.
Nowhere do I see the vital statistics of the dreams of the poor, of native peoples, of the elderly, of the sick and dying. When we have an accurate medical sample of everyone's dreams we will be able to discern the true nature of everyone's health concerns. If we were able to collect the dream texts of 6.8 billion individuals from around the planet, what we will find is the psychodynamics of healthy and unhealthy being. The failed dream work of many is washing over the planet as we speak. A vicious generational semiotic cycle of the medical plotting, speaking, writing and reading about failed dream work caused by social problems exists.
In summary, the dream has remained a durable medical and literary device which has poetically guided humanity from its' beginnings and will continue to ritually do so till its' end. The dream text is viewed as a biographical, literary and clinical document. Providing access to clinical information often not otherwise retrievable, the dream facilitates the clinicians ability to accurately diagnose and treat. Marshal McLuhan has told us that because we live in the electronic information age we are being retribalized and reconnected into a Global Village. If this is true, then it will become increasingly important to medically understand the interconnectedness of our Village and the total dream of being human.