*4.2.2. The second phase: realization of therapeutic goals*

The second phase of the CBT process is focused on the realization of therapeutic goals. It aims to improve the functioning and quality of life of the patient. This improvement is achieved with specific therapeutic interventions resulting from the case formulation. During this stage, a variety of techniques focused on cognitive, behavioral, and emotional changes is used [28].

One of the most basic CBT methods which is also classified as a therapeutic approach within the framework of CBT is cognitive restructuring. Dreams may facilitate this process [2]. The reformulation of dream content has the same structure as working with automatic thoughts. The goal of this intervention is to change dysfunctional themes of dreams and their affective impact by appropriate disputation and rational challenges to maladaptive dream material [8].

**Disorder Cognitive specificity Dream content (in comparison to the non-**

Depression Negative assessment of self, the world

Anxiety disorders Focus on physical or psychological threats

Eating disorders Excessive focus on issues related to eating,

Triad) [22]

[28]

[58]

Borderline personality disorder and the future (Beck's Negative Cognitive

appearance, weight and body shape [57]

The world and other people are dangerous and malevolent; the self is powerless, vulnerable, and inherently unacceptable

**Table 1.** A comparison of cognitive specificity and dream content in selected psychiatric disorders.

**clinical population)**

body distortions [53]

patients [53]

Higher rate of nightmares [55]; more negative mood tone (not confirmed in all studies [53]); more passive role of the dreamer [56]

Dreams in Cognitive-Behavioral Therapy http://dx.doi.org/10.5772/intechopen.70893 109

psychological trauma; less friendly interactions

More dreams of food (or food rejection) and

More distressing dreams that may portray traumatic childhood experiences and main emotional and interpersonal concerns of

Anticipation of physical harm and

with other dream characters [53]

Dream content, the same as automatic thoughts, can be recorded within the homework and then be a part of the therapeutic work during the session. Two reporting techniques are used

Importantly, in therapy it is possible to work not only on individual dreams, but also on series of dreams. Dream series can provide a lot of information about the patient and reflect changes in his/her state of mind and progress in therapy. Moreover, they can reveal repetitive dream elements which may be clinically important [42]. If the patient and the therapist want to work on dreams during therapy sessions, it is recommended to look at more than just one dream.

The goal of the therapeutic process in CBT is to change the maladaptive and unhelpful cognitive, emotional, and behavioral patterns of the patient, as well as to teach him/her to be their own therapist. The last stage of CBT is aimed at a summary of these changes, re-evaluation of the therapeutic goals established at the beginning of the therapy, and relapse prevention [28]. Working with dreams in therapy is beneficial when it leads to changes in the patient's emotions, cognitions, and/or behavior. These changes may be related to the patient's dreams or to his/her waking life generally. The therapist and the patient can explore how changes related to dreams may be applied to his/her waking concerns [4, 42]. During the last stage of CBT, the therapist and the patient summarize what was helpful for the patient, which

Moreover, when working with dreams in therapy, metaphors can be useful [59].

in relation to dreams: the Dream Log and the Dream Analysis Record [18, 19].

*4.2.3. The third phase: evaluation and preservation of therapeutic achievements*

Before focusing on CBT methods that can be helpful when working with dreams, it is worth discussing the relationship between the continuity hypothesis [50] and the cognitive contentspecificity hypothesis [51]. The continuity hypothesis formulated by Hall [50] states that "dreams are continuous with waking life." In dreams, the same personalities with the same characteristics, beliefs, convictions, wishes, and fears are presented as in the waking state [50]. The continuity hypothesis is broadly discussed and studied [52, 53]. The cognitive contentspecificity hypothesis, which is a component of Beck's cognitive theory, states that psychopathological symptoms can be differentiated on the basis of their unique cognitive content, such as automatic thoughts and/or beliefs [50]. This hypothesis is also studied [54]. If these two hypotheses are combined, the conclusion may be that dream content in individuals with diagnosis of specific psychiatric disorders may be continuous with the cognitive content from their waking state. Dreams of patients diagnosed with various psychiatric disorders are continuous with some aspects of their waking life. On the other hand, dreams also reveal several discontinuities from their waking experiences [53]. Research on the relationship between waking/ dreaming experiences and cognitive and emotional patterns has still not gone deep enough. A detailed review on dream content in specific groups of patients is not possible in the chapter but in **Table 1**, a compilation of results concerning cognitive content and dream content in selected psychiatric disorders is presented. Due to the fact that results on the relationship between waking and dream cognitive content are still insufficient, the summary below should be taken with caution and treated as additional information, not as the basis for diagnose or clinical interventions. However, as with automatic thoughts and beliefs, dream content can be discussed during therapeutic sessions; therefore, knowledge about relatively frequent dreams in specific psychiatric conditions may be useful for cognitive-behavioral therapists.


**Table 1.** A comparison of cognitive specificity and dream content in selected psychiatric disorders.

problems" [49]. The case formulation includes, among others, the automatic thoughts, beliefs and schemas, cognitive distortions, typical patterns of behavioral and emotional responses of the patient. This cognitive content may represent both waking and dreaming cognition. As stated earlier, dreams can reveal information about the patient's core beliefs [2], schemas [24], cognitive distortions [2], patterns of behaviors [15], and patterns of affective responses [23]. All these elements may be incorporated into the case formulation for a better understanding of the patient and the mechanisms behinds his/her problems. Dreams can reveal information that the patient is not aware of or does not currently want to share with the therapist [13].

It seems that dreams may be useful at this stage of CBT in terms of direct and indirect disclosure of information. In this approach, the most important issue is what the patient thinks about his/her own dream, what emotions it evokes in him/her, and what conclusions he/she can draw from it. Research on the use of information obtained from dreams in a case formula-

The second phase of the CBT process is focused on the realization of therapeutic goals. It aims to improve the functioning and quality of life of the patient. This improvement is achieved with specific therapeutic interventions resulting from the case formulation. During this stage, a variety of techniques focused on cognitive, behavioral, and emotional changes is used [28]. Before focusing on CBT methods that can be helpful when working with dreams, it is worth discussing the relationship between the continuity hypothesis [50] and the cognitive contentspecificity hypothesis [51]. The continuity hypothesis formulated by Hall [50] states that "dreams are continuous with waking life." In dreams, the same personalities with the same characteristics, beliefs, convictions, wishes, and fears are presented as in the waking state [50]. The continuity hypothesis is broadly discussed and studied [52, 53]. The cognitive contentspecificity hypothesis, which is a component of Beck's cognitive theory, states that psychopathological symptoms can be differentiated on the basis of their unique cognitive content, such as automatic thoughts and/or beliefs [50]. This hypothesis is also studied [54]. If these two hypotheses are combined, the conclusion may be that dream content in individuals with diagnosis of specific psychiatric disorders may be continuous with the cognitive content from their waking state. Dreams of patients diagnosed with various psychiatric disorders are continuous with some aspects of their waking life. On the other hand, dreams also reveal several discontinuities from their waking experiences [53]. Research on the relationship between waking/ dreaming experiences and cognitive and emotional patterns has still not gone deep enough. A detailed review on dream content in specific groups of patients is not possible in the chapter but in **Table 1**, a compilation of results concerning cognitive content and dream content in selected psychiatric disorders is presented. Due to the fact that results on the relationship between waking and dream cognitive content are still insufficient, the summary below should be taken with caution and treated as additional information, not as the basis for diagnose or clinical interventions. However, as with automatic thoughts and beliefs, dream content can be discussed during therapeutic sessions; therefore, knowledge about relatively frequent dreams

in specific psychiatric conditions may be useful for cognitive-behavioral therapists.

tion needs to be conducted in the future.

108 Cognitive Behavioral Therapy and Clinical Applications

*4.2.2. The second phase: realization of therapeutic goals*

One of the most basic CBT methods which is also classified as a therapeutic approach within the framework of CBT is cognitive restructuring. Dreams may facilitate this process [2]. The reformulation of dream content has the same structure as working with automatic thoughts. The goal of this intervention is to change dysfunctional themes of dreams and their affective impact by appropriate disputation and rational challenges to maladaptive dream material [8]. Moreover, when working with dreams in therapy, metaphors can be useful [59].

Dream content, the same as automatic thoughts, can be recorded within the homework and then be a part of the therapeutic work during the session. Two reporting techniques are used in relation to dreams: the Dream Log and the Dream Analysis Record [18, 19].

Importantly, in therapy it is possible to work not only on individual dreams, but also on series of dreams. Dream series can provide a lot of information about the patient and reflect changes in his/her state of mind and progress in therapy. Moreover, they can reveal repetitive dream elements which may be clinically important [42]. If the patient and the therapist want to work on dreams during therapy sessions, it is recommended to look at more than just one dream.

#### *4.2.3. The third phase: evaluation and preservation of therapeutic achievements*

The goal of the therapeutic process in CBT is to change the maladaptive and unhelpful cognitive, emotional, and behavioral patterns of the patient, as well as to teach him/her to be their own therapist. The last stage of CBT is aimed at a summary of these changes, re-evaluation of the therapeutic goals established at the beginning of the therapy, and relapse prevention [28].

Working with dreams in therapy is beneficial when it leads to changes in the patient's emotions, cognitions, and/or behavior. These changes may be related to the patient's dreams or to his/her waking life generally. The therapist and the patient can explore how changes related to dreams may be applied to his/her waking concerns [4, 42]. During the last stage of CBT, the therapist and the patient summarize what was helpful for the patient, which methods were the most useful, what he/she has learned, his/her new adaptive thoughts and beliefs, and what he/she can do when there is a risk of the problem reoccurring [28]. All these interventions can also be used in the case of dreams. The methods of working with dreams, the main conclusions drawn from dreams, and the useful materials about dreams that the patient can refer to after therapy should be mentioned during the last therapeutic sessions.

**References**

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[2] Montangero J. Using dreams in cognitive behavioral psychotherapy: Theory, method

[3] Heaton KJ, Hill CE, Hess SA, Leotta C, Hoffman MA. Assimilation in therapy involving interpretation of recurrent and non-recurrent dreams. Psychotherapy. 1998;**35**:147-162.

[4] Hill C. Working with Dreams in Psychotherapy. New York: Guilford Press; 1996. p. 49

[5] Aurora RN, Zak RS, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Maganti RK, Ramar K, Kristo DA, Bista SR, Lamm CI, Morgenthaler TI. Best practice guide for the treatment of nightmare disorders in adults. Journal of Clinical Sleep Medicine.

[6] Cranston CC, Davis JL, Rhudy JL, Favorite TK. Replication and expansion of "best practice guide for the treatment of nightmare disorders in adults". Journal of Clinical Sleep

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[9] Beck AT. Cognitive patterns in dreams and daydreams. In: Masserman JH, editor. Dream Dynamics. New York: Grune & Stratton; 1971. p. 2-7 (citations, in order, from p. 3 and 7)

[10] Gonçales ÓF, Barbosa JG. From reactive to proactive dreaming. In: Rosner RI, Lyddon WJ, Freeman A, editors. Cognitive Therapy and Dreams. New York: Springer Publishing

[11] Barrett D. The "Royal Road" becomes a shrewd shortcut: The use of dreams in focused treatment. In: Rosner RI, Lyddon WJ, Freeman A, editors. Cognitive Therapy and

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