The Interpretations of Dreams in Clinical Work (Workshop Series of the American Psychoanalytic Association, Monograph 3): Chapter 14 Conclusion (1987). (78): 197–203.

In concluding this third volume of the Workshop Series of the American Psychoanalytic Association I am aware of a continuity with what I noted in concluding the first two volumes of the series. In addition, I am reminded that one of the goals of this concluding chapter is to make a statement of the state of the question(s) that served as the facilitating frame of reference for the workshop that resulted in this monograph.

In 1985, I began the concluding chapter to Models of the Mind: Their Relationships to Clinical Work by noting that:

In writing these concluding remarks I am acutely aware that my commitments to the structural hypothesis and to a metatheoretical perspective on its evolutionary development significantly influence my experience of the alternative theories upon which I am about to comment. … Nevertheless, I have been able to “try a theory on,” to immerse myself in it in an attempt to experience its usefulness in analytic work. These experiences have convinced me that there is considerable value in thinking about what might be helpful in the ideas of colleagues with whom I have considerable disagreement.

In reading the contributions to this book it is clear that each author has a more or less defined model of the mind that organizes his concept of the dream work and his theory of technique; that is, each author has a psychological theory and a derivative theory of what the mind of the patient is doing while he is sleeping and dreaming and what the therapist should or should not do with reported dreams in their clinical work.

At this point I will briefly outline the model of the mind that organizes my clinical work with dreams. This outline can then serve as a frame of reference for the comments that comprise the remainder of this chapter.

My model draws heavily on Freud (1900, 1914a, 1923a, 1926, and 1937), Waelder (1930), Arlow and Brenner (1964), and Brenner (1982). (For a more detailed statement of my understanding of the structural hypothesis and its relationship to the dream work, see Rothstein [1983].) In my view the structural hypothesis suggests the metapsychological premise that the mind is comprised of structures (id, ego, superego) that organize the experience of mental life. The phrase “mental life” refers to an individual's fantasies (conscious/unconscious) that have ideational and affective components. From this perspective all fantasies and their derivative enactments are conceived of as compromise formations created by contributions of these structures. The dream and all other data of the clinical situation are viewed, from this perspective, as compromised formations.

In reading the contributions to this book and the summary of the spontaneous discussions, it is clear that many colleagues are interested in the concept of trauma and in the function of the dream work in assimilating trauma. My view of psychological trauma is quite similar to that described by Dowling in chapter 4 of this monograph and in greater detail in his (1986) contribution to The Reconstruction of Trauma: Its Significance in Clinical Work. From that perspective psychological trauma is defined by the meanings attributed to an experience by an individual.

I conceive of a so-called traumatic dream as I would think of any manifest dream: as a compromise formation. If a manifest dream reported immediately after a trauma portrays solely the traumatic incident and is accompanied by intense anxiety approximating a nightmare, I understand the most obvious aspect of dream work to be the mechanism of repetition that Freud (1920) described under the rubric of the “original function” of the dream work. The ego in the dream work is attempting to assimilate the disturbing affect and simultaneously to create the illusion of undoing the experience. The therapist's response is similarly aimed at facilitating the ego's assimilation of the disturbing experience. At first this may consist solely of listening to the dream in an appropriately therapeutic manner. However, my perspective on the dream work suggests that it is characterized by a number of mechanisms subsumed under the rubric of its multiple functions. The proposal that the ego in the dream work is attempting to create the illusion of undoing the experience conceives of a wish fulfilling motive as an intrinsic aspect of

the ego's efforts at assimilation. I (1983) have suggested that there is a gratifying restoration of a fantasy of narcissistic perfection for the “self representation as agent” associated with the illusion of undoing and/or being in control of an experience. I have described this narcissistic identificatory aspect of the dream work under the rubric of a “narcissistic function” (Rothstein, 1983, pp. 137–139) of the dream work and conceived of this function as a “bridge” between the original and wish fulfilling functions of the dream work. This perspective on the dream work emphasizes that the mind's structures are continually organizing and interpreting experience. This psychological elaboration of the experience considered traumatic accounts for the fact that many so-called traumatic manifest dreams portray the trauma in some subtly changed manner. It is the associations to these elaborations in the manifest dream that facilitate insight into the more latent and unique personal meanings of an experience to an individual. Thus, although a therapist may choose to focus on the assimilation of the disturbing affective component of a reported dream, he is aware that the subtle elaborations of the manifest content lead to more latent meanings organized by a variety of dream work mechanisms including those of condensation, displacement, and symbolization that Freud (1900) first described under the wish fulfillment function of the dream work. Finally, in my experience, it is often the analysis of the unconscious guilt associated with the individual's interpretation of a traumatic experience that facilitates a diminution in the frequency and intensity of repetitive “traumatic” dreams.

An important focus of the workshop that resulted in this book was an exploration of the value of the manifest content. Virtually all the contributors placed some value on the manifest content, and many seemed to employ it in their daily work in a manner that Spanjäard (1969) suggested: “to evaluate the most superficial layer of the conflict” (p. 224). However, from my perspective there was a tendency in some of the chapters to make more of the manifest content than I believe is warranted. In that regard I suggest it is misleading to give a dream a label, such as a “self-state” or “traumatic” dream or a dream of “mourning,” “separation,” “loss,” “termination,” or “of the analytic undisguised.” Such labels tend to imply a unifactorial dynamic in the construction of the dream that organizes the therapist's attention and may inhibit further exploration of the meanings of the dream. For example, so-called repetitive

dreams of mourning which deal, in part, with the assimilation of loss also deal with a panoply of related meanings, such as unconscious aggressive wishes toward the deceased and associated guilt. The repetitive nature of these dreams may be influenced as much by a need to expiate guilt as it is to mourn.

Bradlow has pursued a truly original methodology to explore the value of the manifest dream for prediction in psychoanalysis and psychoanalytic psychotherapy. Although most colleagues applauded Bradlow's efforts, many would be cautious about making generalizations from manifest dreams. A number of colleagues gave examples of successful work with patients who had manifest dreams of the kind that Bradlow suggested were associated with a guarded prognosis. While I also applaud Bradlow's efforts, a number of cautionary notes are indicated. There is a question of the influence of an analyst's interest in prediction, analyzability evaluations, and questions of diagnosis on the evolving opening phase of treatment. My own view of these efforts is that they may subtly affect an analyst's attitude and may hinder trials of analysis with selected sensitive patients.

In addition, Bradlow presents the manifest content of dreams as if it were equivalent to the latent content. He describes a “murder dream” as if it were a direct expression of “severe impounded rage” and implicitly makes strong inferences concerning impaired and possibly unanalyzable character structure. In that regard, in response to a manifest dream of “sexual activity between family members” Bradlow notes, “A failure of the synthetic function of the ego might be involved.”

While it is certainly true, as Rangell noted, that, “Trivialities during the day are unable to pursue us in our sleep”, it seems clear that disturbing events of the dream day can. Thus, “dreams from above” reflect, in part, the ego in the dream work attempting to assimilate disturbing experiences of the day. However, these disturbing events are often experienced as contemporary narcissistic injuries and resonate with the narcissistic injuries of childhood. In the discussion of “self-state dreams” Ornstein discussed his patients' dreams as if they were solely “dreams from above”; that is exclusively created in response to disturbing events of the dream day.

Ornstein presented Kohut's concept of the “self-state” dream as a dream with a different structure and function: “the bind[ing of] the non-verbal tensions of traumatic states” (Kohut, 1971, p. 108). What was, in 1971, a type of dream has become for Ornstein in 1986 a revolutionary alternative to traditional dream theory. Ornstein stated: “It is this elevation of the … regulatory, and restorative function of dreams to a supraordinate position in dream psychology … that has radically transformed dream theory and the understanding of dreams in the clinical situation” (p. 103).

I would suggest that Ornstein's model of the mind and its resulting “dream psychology” creates a technique, a methodology of clinical work, that is radically different from the methodology of colleagues working from a conflict model. Rather than discovering a new dream, Ornstein's supraordinate interest in restitution promotes a radical shift of attention in the clinical situation. His interest in the expression of subtle or not so subtle shifts of integration and his responses aimed at facilitating “restitution,” influence him to be less interested in the latent meanings of dreams. Therefore it is not so much as Kohut suggests of “self-state” dreams that there are objectively no further deepening associations to a dream, but that for an analyst working with a dream from the perspective of psychology of the self, there are no further deepening associations to certain dreams, while to an analyst working from a traditional perspective that stresses the interminability of conflict there are always further deepening associations which he may or may not choose to pursue.

In that regard concepts like “defect” and “fragmentation,” and the clinical data often attributed to them such as a patient's tension laden states or sense of void and/or complaints of feeling empty, are conceived, like “self-state” dreams, as end states. I would emphasize that these concepts and the related clinical states of mind can be thought of as manifest content, as fantasies that can be associated to in order to explore their more latent and overdetermined meanings.

Finally, a great deal of discussion focused on the question, “Is the dream a special kind of data?” It was clear that many colleagues felt a particular attraction for dreams. In addition to the many factors cited to explain this phenomenon, it may be that dreams are an important focus of many analysts' ongoing self-analyses. It is equally clear that colleagues were

aware that whatever their personal or scientific interest in dreams, if that interest is excessive, it certainly can influence their clinical work and the dreams reported in it. In that regard, the principle of neutrality provides a clinical ideal that can facilitate a more optimal attention to all the data of the analytic experience.

In concluding Monograph 1 of this series, it was clear “that significant disagreement exists and questions remain relating to our understanding of the relationships of preoedipal to oedipal and postoedipal experience” (Rothstein, 1985, p. 135). In concluding Monograph 2 I noted:

This book clearly demonstrates that although colleagues use the same terms to describe what they do, these terms have a variety of meanings. It is also likely that different colleagues function differently in their clinical work. It seems probable that within the term analysis there are a number of analyses practiced by a variety of analysts for a spectrum of patients (1986, p. 229).

These differences are relevant to considerations of the differences of emphasis encountered in the various contributions to this volume. It is clear from these contributions that analysts think differently about dreams and work differently with them in their clinical practice. Significant differences exist concerning the value of the manifest content of the dream and concerning the interpretation of a dream as a “concrete puzzle solution” within a given paradigmatic perspective. One colleague might focus on facilitating “restitution” while another might choose to interpret resistance and pursue latent meanings. In the pursuit of meaning one colleague might listen to the associations to a dream from a perspective that organizes data in a manner that favors reconstruction of hypothesized preoedipal trauma with resulting arrests of development while another might listen from an organizing perspective that favors oedipal interpretations. The latter would emphasize the centrality of conflict and compromise formation and would interpret one or another aspect of the compromise: drive, defense, and/or the influence of conscience. At this time in the history of psychoanalysis we are confronted with the fact that no sound research methodology exists for resolving the differences that characterize our field and which are demonstrated in this volume. The development of additional research perspectives beyond the analytic method itself could help explore a number of questions raised by

the discussions of the workshops. It would be interesting to study the influence of the analyst's personality on his choice and interpretation of his theory or theories. In addition, it would be interesting to compare processes of a number of analysts working with dreams from a variety of clinical perspectives.

Finally, future scientific meetings will contribute to the clarification of some of the questions raised in this book. The 1986 Workshop for Mental Health Professionals on “The Mode of Therapeutic Action of Psychoanalytic Psychotherapy, or How Does Treatment Help?” is of particular value in this regard.