**3.1. Facilitating the therapeutic process**

Working with dreams in therapy can facilitate the therapeutic process in these ways: increasing patient disclosure and comfort; improving his/her attitude toward the therapeutic process and participation in therapy; encouraging his/her engagement and positive involvement in therapy; and enhancing the cooperation and the working alliance between patient and therapist [26]. Moreover, use of dreams can prevent patients terminating therapeutic treatment early [27].

The therapeutic process in CBT includes several components: (a) defining the goal of the therapy; (b) elaborating the ever-evolving case formulation of the patient and his/her problems in 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) limiting the number of sessions [28].

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 therapeutic process.

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 difficult experiences in the course of therapy [30].

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.

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

These guidelines simply and accurately present how cognitive-behavioral therapists can

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

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

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

Dreams can be useful in psychotherapy. Some approaches, like psychoanalysis, actively apply to dreams, whereas others, like CBT, leave them on the periphery of therapeutic work. Eudell-Simmons and Hilsenroth [26] defined four conceptual functions of dreams in psychotherapy. A detailed description of the methodological issues and the basis of this division are available in the original paper [26]. Due to the scope of the chapter, we focus on the functions

Working with dreams in therapy can facilitate the therapeutic process in these ways: increasing patient disclosure and comfort; improving his/her attitude toward the therapeutic process and participation in therapy; encouraging his/her engagement and positive involvement in therapy; and enhancing the cooperation and the working alliance between patient and therapist [26]. Moreover, use of dreams can prevent patients terminating therapeutic treatment early [27].

The therapeutic process in CBT includes several components: (a) defining the goal of the therapy; (b) elaborating the ever-evolving case formulation of the patient and his/her problems in

lifetime and is dysfunctional to a significant degree (for more, see: [24, 25]).

**3. A functional perspective on working with dreams in CBT**

usage of experiential methods in the schema change phase [24].

of CBT is still lacking.

of dreams in terms of CBT.

**3.1. Facilitating the therapeutic process**

work with dreams within this therapeutic approach.

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

102 Cognitive Behavioral Therapy and Clinical Applications

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 patient is important [31].

In the course of CBT, the patient generally has two opportunities to gain new self-knowledge. Firstly, within collaborative empiricism, which involves a systematic process of the patient and the therapist working together [32], the patient's dysfunctional thoughts, beliefs, schemas, and coping strategies are identified [28]. Secondly, during psychoeducation, the therapist provides important information about the mechanisms of disorders, relapse prevention, and so on for the patient [28].

**3.4. Providing a measure of therapeutic change**

of the patient's functioning in the waking state.

within the framework of CBT.

a few theoretical papers.

The last conceptual use of dreams in therapy refers to using dreams as a measure of therapeutic change. Dreams can provide information about the patient's functioning outside of therapy and indicate therapeutic change or improvement of the patient due to therapy [26]. Changes in dream content can occur not only when the therapeutic goal assumes working on dreams, but also when other goals, even those not related to dreams, have been accomplished. A shift in a dream can indicate that clinical improvement in relation to personality development and behavioral change has been achieved [26]. Interestingly, the anxiety content of dreams increases in patients who are successful in therapy. This possibly reflects an increase in tolerance and ability to cope with anxiety when awake [34]. These findings need to be examined in terms of CBT. However, even now it is recommended for therapists to bear in mind that an increasing level of anxiety in dreams may, paradoxically, not be a sign of worsening, but of improvement. Notwithstanding, the decision concerning whether an increasing level of anxiety in dreams is positive or not should be always be based on the broader context

Dreams in Cognitive-Behavioral Therapy http://dx.doi.org/10.5772/intechopen.70893 105

Overall, dreams have the potential to indicate therapeutic change. In CBT, this way of evaluation of improvement may be additional to other methods, such as scales. Research on the mechanisms and directions related to therapeutic change and dreams needs to be conducted

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

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

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

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

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

psychotherapeutic practice, especially CBT, is scarce.

The patient extends his/her self-understanding when discussing his/her waking mental content with the therapist. However, dreams can also be a source of self-knowledge [26]. With reference to CBT, dreams may contain information about cognitive patterns [9], schemas [24], and cognitive distortions [2]. Dreams can also bring forth information about a patient's feelings toward various situations and experiences.

Individual's dreams can contribute to therapy by increasing the self-knowledge of the patient. The information obtained from discussing dreams can potentially lead the patient to greater self-understanding. Moreover, they can enhance the patient's motivation for therapy and provide the knowledge needed to change dysfunctional cognitive and behavioral patterns [26].
