**2.2. Clara E. Hill: the cognitive-experimental model of dream interpretation**

One of the most elaborated and well-documented method of working with dreams in psychotherapy sessions is Hill's cognitive-experimental model of dream interpretation. It was developed in the 1990s based on psychoanalytic, existential-phenomenological, gestalt, cognitive, and behavioral approaches [4]. Due to the variety of sources of Hill's model, it is not directly recognized as a part of CBT. However, it can be used within CBT as an integration model that applies to Beck's concept of cognitive therapy as integrative therapy [18, 19]. This method is broadly presented elsewhere [4, 20].

According to Hill [4], dreams are a continuation of waking thoughts and therefore their meaning is personal. They contain cognitive, behavioral, and emotional components. Working with dreams assumes collaboration between the therapist and the client,1 who is the main figure in this process. The goal of working with dreams is to introduce changes in the way clients think, feel and behave, and to develop their self-understanding [4].

The cognitive-experimental model of dream interpretation comprises the three following stages: (a) exploration, (b) insight, and (c) action. The first stage, consists of five steps: (a) explaining the model; (b) re-telling the dream; (c) exploring overall feelings and the timing of the dream; (d) exploring images according to DRAW method (description, re-experiencing, associations, waking life triggers); and (e) summarizing [20]. During the exploration stage, the client has an opportunity to reveal relationships between the dream and waking life [4, 20].

When dream images have been explored, the insight stage is introduced. It is divided into three steps: (a) asking the client for an initial understanding of the dream; (b) establishing the meaning of the dream; and (c) summarizing [20]. During this stage, the therapist and the client collaborate to establish the meaning of the dream [4].

The action stage has three steps: (a) changing the dream; (b) encouraging the client to make changes in his/her waking life; and (c) summarizing. Changing the dream may refer to the therapist asking the client to alter the dream in his/her imagination or create a continuation of the dream. The therapist encourages the client to think about ways in which he/she would like to change the dream plot. Hill [20] describes three possible kinds of actions: (a) behavioral changes; (b) rituals, and (c) continued work on the dream. In this stage, the therapist can also teach the client new ways of behavior, or encourage her/him to use skills she/he has already but is afraid to put into practice [4].

<sup>1</sup> Hill [4] uses term "client" instead of "patient." We follow this nomenclature to describe the cognitive-experimental model of dream interpretation; however, in all chapters we decided to use term "patient" in order to simplify the nomenclature.

### **2.3. Jacques Montangero: the description, memory sources, and reformulation method**

Montangero claims that "dreaming is a primarily cognitive phenomenon since it consists of creating representations, that is, evoking things that are absent by means of substitutes like mental images, words, etc." [21]. Dream representations are not meaningless; they are related to a person's aspirations and concerns and they are often complementary to topics from the preceding day that one does not want to or has no time to think about. Therefore, the meaning of dreams is not univocal, but personal [21].

The goal of the systematic procedure of dream interpretation developed by Montangero [2] is to reveal this personal meaning of dream elements. The description, memory sources, and reformulation method (DMR) was elaborated in the 1980s and improved until the early 2000s [21]. The method has three steps: (a) complete description, (b) search for mnemonic sources, and (c) reformulating the dream description.

In the first step, the patient has to immerse in the memory of his/her dream. He/she shares the dream content with the therapist, who writes down this description. The second step is focused on connecting the dream elements to autobiographical memories in order to clarify the meaning of the dream. The aim of the third step is to describe the dream content as a sequence of more general terms. The patient and therapist collaboratively categorize and find a definition or function for each element of the dream. These general ideas could later be applied to the patient's aspirations or concerns. Reformulation of the dream leads to its interpretation, which is based on relationships between dream elements and waking experiences of the patient [2, 21].

Montangero established the DRM method as a part of CBT as it has several general methodological principles in common with this approach; for instance, both the DRM and CBT use a systematic analysis of the mental content of the patient [21]. We were unable to find any empirical research on this model.

#### **2.4. Arthur Freeman: guidelines for using dreams**

other factors that may influence the fact that cognitive-behavioral therapists do not consider dreams as important: lack of training in the use of dreams in CBT, lack of a manual dedicated to dream work in this approach, and regarding dreams as unconscious or having no direct behavior component. Despite these reasons for the lack of interest in dreams in CBT, a few methods and guidelines for using dreams in this therapeutic approach have been developed.

One of the most elaborated and well-documented method of working with dreams in psychotherapy sessions is Hill's cognitive-experimental model of dream interpretation. It was developed in the 1990s based on psychoanalytic, existential-phenomenological, gestalt, cognitive, and behavioral approaches [4]. Due to the variety of sources of Hill's model, it is not directly recognized as a part of CBT. However, it can be used within CBT as an integration model that applies to Beck's concept of cognitive therapy as integrative therapy [18, 19]. This method is

According to Hill [4], dreams are a continuation of waking thoughts and therefore their meaning is personal. They contain cognitive, behavioral, and emotional components. Working with

this process. The goal of working with dreams is to introduce changes in the way clients think,

The cognitive-experimental model of dream interpretation comprises the three following stages: (a) exploration, (b) insight, and (c) action. The first stage, consists of five steps: (a) explaining the model; (b) re-telling the dream; (c) exploring overall feelings and the timing of the dream; (d) exploring images according to DRAW method (description, re-experiencing, associations, waking life triggers); and (e) summarizing [20]. During the exploration stage, the client has an opportunity to reveal relationships between the dream and waking life [4, 20].

When dream images have been explored, the insight stage is introduced. It is divided into three steps: (a) asking the client for an initial understanding of the dream; (b) establishing the meaning of the dream; and (c) summarizing [20]. During this stage, the therapist and the cli-

The action stage has three steps: (a) changing the dream; (b) encouraging the client to make changes in his/her waking life; and (c) summarizing. Changing the dream may refer to the therapist asking the client to alter the dream in his/her imagination or create a continuation of the dream. The therapist encourages the client to think about ways in which he/she would like to change the dream plot. Hill [20] describes three possible kinds of actions: (a) behavioral changes; (b) rituals, and (c) continued work on the dream. In this stage, the therapist can also teach the client new ways of behavior, or encourage her/him to use skills she/he has already

Hill [4] uses term "client" instead of "patient." We follow this nomenclature to describe the cognitive-experimental model of dream interpretation; however, in all chapters we decided to use term "patient" in order to simplify the

who is the main figure in

**2.2. Clara E. Hill: the cognitive-experimental model of dream interpretation**

dreams assumes collaboration between the therapist and the client,1

feel and behave, and to develop their self-understanding [4].

ent collaborate to establish the meaning of the dream [4].

broadly presented elsewhere [4, 20].

100 Cognitive Behavioral Therapy and Clinical Applications

but is afraid to put into practice [4].

1

nomenclature.

According to Freeman, a dream is a representation of an idiosyncratic dramatization of the dreamer's view of the self and the world. It reflects the waking cognitions and affective responses of the individual, not the "mysterious reflections of so-called deeper issues" [8]. Appealing to dream symbols should also be avoided; hence, in therapy, a dream should be understood in terms of the patient's life and his/her experiences from waking states [8].

Arthur Freeman has been working on dream analysis in CBT since the 1980s [8, 22, 23]. He had to rely on Beck's early papers because in other sources he failed to find any references to dreams, dreaming, or the use of dreams in CBT [14]. He listed points concerning "cognitive dream interpretation." The most recent version contains rules as, for instance: understand the dream in thematic rather than symbolic terms; the thematic content is idiosyncratic to the dreamer and must be understand within the context of his/her waking life; the affective responses to the dream image can be seen as similar to the emotional responses of the patient in waking life; dream content and images come under the same cognitive restructuring methods as automatic thoughts; the dream may reflect the patient's schema. The complete version is described elsewhere [8].

These guidelines simply and accurately present how cognitive-behavioral therapists can work with dreams within this therapeutic approach.

cognitive terms; (c) emphasizing the present in the first phase of therapy; (d) structuring the therapeutic process and every therapeutic session; (e) establishing a good patient-therapist relationship; (f) collaboration between the patient and the therapist and the active participation of both in the therapeutic process; (g) emphasizing the role of psychoeducation; (h) using a variety of techniques to change thinking patterns, mood, and behavior of the patient; and (i)

Dreams in Cognitive-Behavioral Therapy http://dx.doi.org/10.5772/intechopen.70893 103

Including work with dreams during each of these steps is plausible if: (a) the goal of the therapy can be defined, for instance, as the changing of an unpleasant dream, or decreasing the negative emotions related to the dream; (b) information obtained from dream content can be incorporated into the case formulation of the patient; (c) in the initial phase of therapy, the patient and the therapist can focus on the last dream or unpleasant/important dreams as the basis for extension of their therapeutic work; (d) working with dreams can be planned within the whole course of therapy; (e) working with dreams can facilitate the therapeutic relationship [26]; (f) the methods of dream analysis require collaboration between the patient and the therapist and their active participation in the process of dream interpretation; (g) information about the process of dreaming and sleeping can be a part of psychoeducation; (h) a variety of standard CBT techniques can be used to work with dreams; and (i) the patient and the therapist can establish the amount of time devoted to working with dreams in each session, as well the entire thera-

According to Safran et al. [29], a good therapeutic relationship in CBT consists of: (a) interpersonal processes, (b) alliance ruptures, and (c) the patient's emotions. Effective collaboration between the patient and the therapist increases the chances of therapeutic change and the healing of dysfunctional schemas. Schemas can be also present in dreams and work on dream content can facilitate modification of these unhelpful schemas [24]. For patients who have problems in establishing a good collaborative relationship with the therapist, the recounting of dreams may help to develop trust in the therapist more quickly and deeply. Working with dreams can also encourage the patient to introduce and/or pursue issues that otherwise may have been too difficult, painful, or embarrassing to discuss with the therapist [13]. Hence, elaborating on dreams can positively influence the interpersonal processes between the patient and the therapist [28]. There is a variety of methods for dealing with difficulties in therapy, one of which is to refer to dreams [26]. Finally, yet importantly, the patient's emotional arousal is necessary for the therapeutic progress [28]. Some dreams have a great emotional impact; therefore, working with them can be useful when processing the patient's

Dream analysis can bring multi-faceted support to the therapeutic process. As indicated, work with dreams can be incorporated into each element of the therapeutic process in CBT. However, this is a theoretical analysis that needs to be verified in empirical studies.

One of the goals of therapy is to enhance self-awareness or self-knowledge of the patient. Alternatively, it is called insight, understanding, or recognition [26]. Although, the term "insight" is traditionally not used within CBT, the process of fostering self-awareness of the

limiting the number of sessions [28].

difficult experiences in the course of therapy [30].

**3.2. Facilitating self-knowledge of the patient**

patient is important [31].

peutic process.

#### **2.5. Jeffrey Young: schema therapy and dreams**

Schema therapy is an integrative therapy that significantly expands on traditional CBT. It was developed by Young and colleagues in 1990. One of the main assumptions of schema therapy states that schemas, which have their source in toxic childhood experiences, might be the core of a number of psychological problems. Such schemas were labeled as early maladaptive schemas; these are defined as a broad, pervasive theme or pattern comprised of memories, emotions, cognitions and body sensations regarding oneself and one's relationships with others that was developed during childhood or adolescence and elaborated throughout one's lifetime and is dysfunctional to a significant degree (for more, see: [24, 25]).

Two phases of schema therapy were established: (a) the assessment and education phase and (b) the change phase. According to Young [24], schema therapy can refer to dreams in both stages. Schemas are triggered during various experiences during a patient's life; they can be present not only in waking mentation, but also in dreams. Recurrent dreams and those with strong affect are most important. A patient can record his/her dreams and discuss them with the therapist. Dream content can reveal a patient's schemas in the first stage of schema assessment. Furthermore, recounting a dream can be a starting point for imagery work related to usage of experiential methods in the schema change phase [24].

The aforementioned tips for working with dreams in schema therapy are the only ones that have been formulated so far. Empirical research on working with dreams in the third wave of CBT is still lacking.
