**4.2. Phases of CBT**

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

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

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

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

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

willingness to elaborate on dreams during therapy sessions [36].

needed, as it has not yet been elaborated on.

these traits [26].

in other studies [42, 43].

sessions.

106 Cognitive Behavioral Therapy and Clinical Applications

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.

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

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

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 information for the therapist to understand the patient better.

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

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 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 formulation needs to be conducted in the future.
