**4. A processual perspective on working with dreams in CBT**

The processual perspective on dreams in CBT is focused on some practical aspects of working with dreams in the course of therapy. There is hardly any research on dreams in CBT and only a few theoretical papers.

#### **4.1. Characteristics of patients and therapists who work with dreams**

Therapists who participate in studies on working with dreams in therapy are mainly oriented toward psychoanalytic and psychodynamic approaches. This is related to the fact that dream theories and manuals for dream analysis have seldom been available in other therapeutic approaches, including CBT [35]. Systematic research on the frequency of use of dreams in psychotherapeutic practice, especially CBT, is scarce.

Schredl and colleagues [35] checked the frequency of use of dreams in 79 therapists with private practices. The results revealed that in about 28% of therapy sessions, the topic of dreams is discussed. Therapists had introduced work with dreams in 33% of cases. Schredl et al. [35] divided the total sample of therapists into two categories: (a) psychoanalysts and (b) humanistic and cognitive-behavioral therapist. Compared to humanistic and cognitivebehavioral therapists, psychoanalysts more often refer to dreams, regard work on dreams as more beneficial for patients, and report the greater enhancement of dream recall in patients. Representatives of psychoanalysis have also read more literature about dreams, and more often work with their own dreams in comparison to humanistic and cognitive-behavioral therapists. The findings indicate that working with dreams in therapy still plays an important role and is considered beneficial in the therapeutic success [35]. In CBT, the literature about dreams is still lacking; therefore, cognitive-behavioral therapists possibly less often work with their own dreams and less willingly develop dream-related issues during therapeutic sessions.

The therapists' encouragement to talk about dreams in therapy is an important factor when considering bringing dream content into therapy sessions [43]. A vast majority of cognitivebehavioral therapists have not been trained to work with dreams in therapy; therefore, they do not feel competent to discuss such issues. There are studies on the characteristics of therapists and patients who work with dreams in therapy, but no such studies have been con-

Dreams in Cognitive-Behavioral Therapy http://dx.doi.org/10.5772/intechopen.70893 107

The three phases of the CBT process are distinguished: (a) clinical diagnosis and case formulation; (b) realization of therapeutic goals; and (c) evaluation and preservation of therapeutic achievements [29]. Our proposition to work with dreams within all these stages is presented.

The first phase of CBT usually takes a few sessions. It is a very important part of the whole therapeutic process because decisions concerning the treatment plan and clinical interventions are made at this stage [28]. During diagnosis, the therapist can broaden the standard clinical interview with questions concerning dreams; for instance, he/she can ask the patient about the last remembered dream, the most important dream, recurrent dreams, the emo-

Beside the standard clinical interview, the therapist can also adopt the dream interview model (DIM) elaborated by Delaney [44]. It is based on the assumption that dream images are symbols or metaphors representing waking experiences of the patient. It can be used as a separate method of dream interpretation; however, the initial steps can also especially be used in the first phase of CBT as a technique that facilitates the process of obtaining information about the patient and his/her dreams. DIM is not dedicated to CBT, but it can be used within this approach due to the integrative assumptions of CBT made by Beck and Alford [18, 19]. DIM is described in detail elsewhere [44]. It may be used within CBT as a method of gaining information about a dream, the patient's feelings and opinions about that dream, and relationships between dream images and his/her waking experiences. Importantly, clinical diagnosis cannot be based on only dreams. Information related to dreams may only be additional informa-

If needed, it is plausible to use questionnaires and scales about dreams in a clinical context. However, it is important to remember that these tools were developed for scientific research and therefore should be used with caution in therapy. Some methods are available to assess attitudes toward dreams: the attitude toward dreams questionnaire [39, 43], and the attitude toward dreams scale [45]. In the course of therapy, the dream recall frequency scale may also be useful [46]. Other methods may be used during clinical diagnosis, for instance the dream

Information about the patient obtained from clinical interviews and other methods serves in CBT to create a case formulation which is "a hypothesis about the psychological mechanisms and other factors that are causing and maintaining all of a particular patient's disorders and

ducted directly in CBT.

*4.2.1. The first phase: clinical diagnosis and case formulation*

tion for the therapist to understand the patient better.

questionnaire [47], and the Mannheim dream questionnaire [48].

tional tone of one's dreams, or the patient's attitude toward dreams.

**4.2. Phases of CBT**

In a study conducted by Cook and Hill [36], 129 therapists rated themselves on a 5-point Likert scale as adhering to techniques of cognitive, humanistic, and psychodynamic approaches on averages of 3.92, 3.26, and 3.08, respectively. Almost all of them (92%) worked with dreams during therapy sessions at least occasionally. Therapists reported that they felt moderately competent or even incompetent when working on dreams in therapy and had moderate or no training in dream work. Such training was strongly related to the aforementioned feelings of competence. Additionally, therapists with more training were likely to devote more time in therapy to work with patients' dreams than were therapists with less training. It seems that training in dream work and therapists' personal experiences with dreams are related to their willingness to elaborate on dreams during therapy sessions [36].

To conclude, cognitive-behavioral therapists have little or no training on working with dreams in therapy. During such training, therapists can gain knowledge about techniques and methods dedicated to work with dreams; therefore, when patients introduce their dreams into therapy, therapists have some idea of how to elaborate on this clinical, narrative material [36]. Lack of knowledge about working with dreams during therapy sessions discourages cognitive-behavioral therapists from discussing dreams with their patients; however, they are somehow more willing to explore dreams in terms of patients' waking experiences than to interpret them [37]. A comprehensive manual concern working with dreams in CBT is needed, as it has not yet been elaborated on.

As the proverb says, it takes two to tango; therefore, there are not only therapists who are open to work with dreams in therapy, but also patients. Patients who remember their dreams more often bring them to therapy than those who do not [26]. Patients who have "thin boundaries" are also more likely to discuss their dreams during therapy sessions [38]. Moreover, patients who have more vivid or memorable dreams and are more attuned to their inner experiences tend to bring dreams to therapy more often than those without these traits [26].

A study on 336 undergraduate students revealed that those who volunteered in a dream interpretation session (N = 109) had a more positive attitude toward dreams, recalled dreams more frequently, were more open, were higher in absorption, and were more often female than the non-volunteers [39]. A study on 157 voluntary participants revealed that those who profited most from discussing dreams during therapy sessions had poor initial functioning related to the problem reflected in the dream, a positive attitude toward dreams, salient dreams, low initial insight into the dream, and poor initial action ideas related to the dream [40]. The importance of attitude toward dreams, understood as an indicator of motivation to work with dreams and willingness to bring dream content in therapy [41], is also confirmed in other studies [42, 43].

The therapists' encouragement to talk about dreams in therapy is an important factor when considering bringing dream content into therapy sessions [43]. A vast majority of cognitivebehavioral therapists have not been trained to work with dreams in therapy; therefore, they do not feel competent to discuss such issues. There are studies on the characteristics of therapists and patients who work with dreams in therapy, but no such studies have been conducted directly in CBT.
