The Use of Dreams in the Evaluation of Severely Disturbed Patients

The use of dreams for diagnostic evaluation in modern psychoanalysis has its ancestry in popular folklore as well as in mankind's most ancient beliefs. Throughout antiquity it was assumed that dreams might deliver hidden messages, revelations, and prophecies. Most famous among these, of course, were the dreams of the Egyptian pharaoh interpreted by Joseph in the Bible. Perhaps less well known but widespread in pre-Christian, Mediterranean culture, was a ritual form of divination and healing known as “dream incubation.” In this practice a sick person would undergo ceremonial preparations before sleeping the night in a sacred cavern or temple: A dream would then provide divine instructions, foreknowledge, or it would bring about a cure by itself. To modern thinking dream incubation is a projection into nature of human concerns, but it also expresses a universal conviction that dreams may convey deep psychological truths not accessible to the conscious mind.1

The contemporary use of dreams for diagnostic evaluation begins with Freud's theory of dream psychology. By explaining neurosis and dreams with one model of unconscious psychic conflict, Freud's method of dream interpretation provided a powerful tool for evaluating psychopathology and its childhood etiology. In treatment there may occur dreams “based on the entire pathogenic material of the case, as yet unknown to both doctor and patient … [and] sometimes equivalent to a translation into dream-language of the whole content of the neurosis” (Freud, 1911, p. 93). Paradoxically, however, a broad diagnostic use of dreams was not part of early psychoanalysis. Freud formulated his theory of dreams in a metapsychology of unconscious wishes and archaic mental processes, and never really updated it in the later structural model. The reductionism of this approach to dreams, however, sacrifices much of their potential diagnostic value. As