BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION Gisela E. Kolb
I believe it to be true that dreams are the true interpreters of our inclinations; but there is art required to sort and understand them.
Montaigne (Essays III) The value of dream interpretation during brief psychotherapy has concerned a number of psychotherapists. Wolberg t has noted that the value of the use of dreams in therapy is dependent upon the therapist's comprehension of dynamics. Greenson2 has pointed up the significance of Gutheil's 3 observation that the dream has declined in clinical importance. He thinks that Freud's4 view of the dream as "the royal road to a knowledge of the unconscious activities of the mi nd" no longer applies. Gutheil blamed the neglect of dream material on a misconception of so-called "free association," a skillful analyst's most important tool. It should be noted, however, that with reference to dream interpretation, free association is not an issue. Associations to dreams are determined and defined by the dream content. This brings us to consideration of the following issue. In brief psychotherapy, how deeply should we penetrate or probe the unconscious, unaided by a patient's associations as possibly revealed in dreams? I think that reintroducing dream analysis into brief psychotherapy can hasten the revelation of problems and conflicts and contribute significantly to shortening the average psychotherapeutic treatment. I have found this technique to be invaluable for analytically oriented brief psychotherapy. It has been my experience that change through insight was blocked, often effectively, by resistance to self-experience. This change was quite common in students who were struggling with independence-dependence conflicts. College, and particularly graduate school, often provides a setting where feelings and values derived from the family of origin can be displaced into the school situation. My patients were all young, married medical students, acting out or fan-
Gisela E. Kolb, M.D., psychoanalyst and Instructor of Psychotherapy,University of Louisville, School of Medicine. The American Journal of Psychoanalysis © 1979 Association for the Advancement of Psychoanalysis
Vol. 39, No. 4, 1979 0002-0958/79/040335-08501.00
335
336
KOLB
tasizing fulfillment of their independence. None of them had achieved a balance between the influence of the family of origin and dependence on their parents on one hand and their ambivalent feelings toward their spouse, children, or marriage on the other. One of the most common modes of symptom presentation was almost monosymptomatic; the conflict was displaced into the context of school. To validate my hypothesis that dream analysis makes brief psychotherapy more productive, I requested my patients to relate their most recent dreams. The results are reported in the following case histories. Case 1
Mr. H., age 26, married, senior medical student, entered therapy because of examination anxieties and indecisiveness about his future specialty and where he should practice. He presented with complaints of headaches, restlessness, sleeplessness, and impairment of sexual potency. At the beginning of the second session he recalled the following dream: We were invited to a party which my wife looked forward to attending. We were leaving the house when she noticed I was wearing a light-blue suit. She asked me to change. When I refused, she elected not to attend the party with me. For clarity, the patient and I divided the dream into three parts: (I) the party invitation, (2) the light-blue suit, and (3) the reaction of the wife. Part I. During his dream associations the patient admitted that he was so involved with his studies that he rarely participated in parties. He also said that his wife complains bitterly about her isolation and his neglect of her. Part 2. With reference to the light-blue suit, he stated: "I can't imagine where this comes from. I have never had a light-blue suit." However, with i n a few minutes he recalled that when he was a little boy his family had moved into a new house. " M y mother told me that I was now old enough to have my choice of room color. I chose light blue. When my father came home he ridiculed me. He felt that light blue was a baby's color and not appropriate for an eight-year-old boy. He forced me to change my color selection." Listening to this association would tempt an experienced analyst to predict that the patient had had an argument with his father on the day prior to the dream, but the temptation was withstood and the patient continued. He recalled that his father had telephoned him early in the evening of the night he had had the dream. The father was impatient to hear his decision with regard to his career. The father favored his staying in his hometown to practice. In fact, he expected it. His father's interference had infuriated the patient. As he talked he showed great ambivalence and stated that he felt like his father was treating him as he would treat a child.
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION 337
Part 3. The patient's wife was also very angry with her father-in-law. Since she worked as a secretary to support her husband she could not understand why he was disturbed by his feelings of obligation toward his father. When the psychotherapist and the patient analyze a dream together, the dream serves as a catalyst. Merrill and Cary describe this situation: The dream serves as a catalyst in establishing sharing and accepting between patient and therapist required in effective brief analytic therapy. The dream process is actualized into experimental reality equivalent to discovery of self external reality. Interpreting dreams close to the manifest level catalyzestheir meaningful relevance to current experience both inside and outside therapy, creating a transitional phase of self-awarenessand self-acceptance,s The dream led to active exploration of the patient's particular conflict and enabled the patient and me to determine that at this critical, transitional period in his life, he had regressed to using old childhood patterns. Using only the skeleton of the latent dream content, the essential material was obtained by simplifying the manifest content. He was not referred to marital therapy, because at this point it was felt that he had to work on his submissive behavior and dependency relationship with his father in individual therapy. The oedipal situation was not touched even though it was obvious, and his ambivalent, emotional bond to his wife was not a focal point. We dealt only with the presenting problem as formalized by the dream analysis. Five individual therapy sessions revealed his relationship with his father to the patient. Emotionally free, he regained his equilibrium, decided to leave his hometown, and to live independent of his father. Case 2
Mr. B., age 27, junior medical student, entered therapy because of extreme anxiety, particularly during examination periods. He presented with insomnia and attacks of tachycardia. Primordial symptoms included: bedwetting until age 12, nail biting, and school phobia. In the first session he spoke openly about problems with his father (he was the eldest son), other authoritative figures, and competition with his brother. Although the latter was two years younger, he was in the same class in school. The patient described his father as domineering, punitive, and overly concerned about his six children. The closed boundaries prevented any of the family from having meaningful relationships outside of the family. Nevertheless, Mr. B. had married one of the first girls he had met because he wanted to get away from home. Now he felt caught in feelings of guilt. In the second session, he reported a dream he had had the previous night. "Last night I dreamed I ran and ran from one store to another in order to buy a
338
KOLB
pipe." (The phallic symbolism and the patient's struggle for his male identity are obvious. It should be noted that symbols may be meaningful to therapists; elucidating them, however, may force the patient into a dependent and passive role. Therefore, a major role of the therapist, particularly in brief psychotherapy, is to create a situation in which the patient becomes active and recognizes his or her part in creating conflicts.) Subsequently, Mr. B. reported another dream. My wife and I were standing at a lake watching a boat departing from the pier. My wife wanted to be on the boat but I tearfully, strongly refused to go and my wife was very angry. The patient associated water with swimming, his first competitive sport. He had loved it as a child. However, one day he had almost drowned, which had occasioned more attention than if he had been a winner. Afterwards, he had given up all competitive swimming and, in fact, all competition. By refusing to go with his wife, he had experienced the same emotions as he had that almost fatal day. Focusing on his passive behavior and his avoidance of competition made his conflict obvious to him. Avoidance had almost cost him his career. Two years earlier, because of examination anxieties, he had left school and had gone to work for a pharmaceutical company. There he also experienced performance difficulties; he did not trust his supervisor, a kind of displacement for the father-teacher. (It became apparent from this and subsequent dreams and the patient's associations that he had many threatening fantasies involving his father and father-authority figures.) Therefore, he had returned to medical school, where he had found himself in the same class with his brother. In one session he concluded that things would be all right if only his family would leave him alone. Thus, he began, by himself, to draw the "correct" conclusions. His observing ego was operating, and the therapist could summarize, clarify, and confront him with his situation in the classroom, where his defense mechanisms such as denial, displacement, projection, etc, could no longer protect him. He also had to deal with the onset of the symptomatology as a compromise of his neurotic conflict. He might then be motivated for certain changes in his life. The third dream reported by Mr. B. gives the full picture: I was living on the street bordering the medical school; my family lived nearby. I was carrying a radio when two guys tried to roll me. My call for help was answered by a classmate. Suddenly, I saw a lot of policemen and asked what they were doing there. Somebody told me that someone had murdered my father. I saw him lying there in a pool of blood, a note attached to his body which said: "We'll get even
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION
339
with you." I thought that the author of the note was one of the fellows who had beaten me up for the radio. I got very anxious for revenge. I told the police I would handle this by myself. I talked with my classmate and asked him to help me find the guilty party. We drove from city to city. Suddenly, I knew where to find the murderer. I knew that he used Dixie Highway. My friend and I were lying in wait on the road when he drove up. We had pistols. When his car stopped, I opened the door and there was the fe! low who had taken my radio and murdered my father. He cried and pleaded with us not to hurt him. I was trembling. I pointed my pistol, shot at him, and ran off. I did not know if l had killed him because my eyeswere closed. Working together, we broke the dream intofour segments: (1) stealing the radio, (2) the murder of the father, (3) "1'11 handle this myself," and (4) revenge. The patient had the choice of priorities in making his associations. Part 1. The radio had a significant association. "It was a Christmas gift from my father when I was 15. It was given to me at a time in my life when I started to have mixed feelings about my father." Part 2. He associated the murder of his father with his difficulties in identifying with his father. Part 3. The patient made it very clear throughout the sessions that he would pay for his therapy himself. In this session he did not follow the "rules." He did not continue by associating the fourth dream segment suggested by the therapist. Instead, he experienced independence in and outside of the therapeutic hour. He allowed himself his own stream of associations. His growing sense of independence enabled him to discuss his sexual conflicts and the way his father confronted him with this issue. During this session, he talked a great deal about him. " M y father is a real salesman. He travels a lot, drinks heavily, and probably has lots of girl friends around the country. I would give anything not to be like him but I see a lot of myself in him." At this point the patient had tears in his eyes. He was overwhelmed by his remembrances of his adolescence and regressed even further. When I was 14, I fell in love for the first time and experienced my first erection. My father found out about it and forced a separation by sending me away to a boarding camp. There, a homosexual priest made advances to me. I begged my Dad to let me come home but he was adamant that I stay. When I did return at the end of the summer, my father engaged me in a long conversation about sex. It was a ridiculous s~ion. He stumbled and stuttered and was obviously embarrassed. I was furious with him but pitied him at the same time. I had always thought of him as a very competent man. One might assume that the deeply fixated roots of this patient's conflicts required a gradual therapeutic exploration available only in long-term
340
KOLB
psychoanalysis. However, a patient's neurotic development can be arrested on whatever level the patient's pathogenic conflicts are liberated. Therapy was discontinued when the presenting problems--ambivalence toward his father and his dependency-independency conflict--became obvious in the acting out and symptomatization. In this case, the focal and remote conflicts were identical. The goal had been to enable the patient to face competition and to feel strong enough to compete with his father without frustration and anxiety stemming from the oedipal constellation. With this in mind, further regression toward homosexuality and preoedipal problems was not pursued. The patient terminated after 30 sessions. Discussion
As these cases illustrate, brief psychotherapy is valuable in dealing with cases where neurotic patterns are obvious for a long period of time. When the patient seems to have adapted through his defense mechanisms and only decompensates in certain stress situations and under most unfavorable circumstances, a brief analytic therapy might be indicated. Trial interpretation in the first one or two sessions can measure the patient's ability to reestablish a new equilibrium. In such cases, analytic theory offers the most systematic hypothesis available. Additionally, the structural aspect, id, ego, superego, operates in a dynamic way to maintain homeostasis. Disturbance in the balance of the internal structure of the personality is disruptive. Therapeutic efforts directed toward corrective specific imbalance can be effective within a short period of time. Brief psychotherapy includes focus techniques. Focus centrally defines the process of concentration, selection, and exclusion in the effort to conclude the therapy within a brief span of time. Therefore, the treatment is anchored to the present and the main objective is to relieve the patient's suffering, particularly his most stressful symptoms. To avoid regression and transference neurosis in brief psychotherapy, the analytic approach should include dream interpretation as Leo Stone, 8 Pietro Castelnovo-Tedesco, 7 and many others have emphasized. The analyst remains effective when he concentrates on the manifest content of the dream and encourages the patient to participate in the therapeutic process by focusing the basis for active change inside and outside of the therapy, alleviating symptoms and acting out of conflicts. The dream process reflects the compromising qualities of the intrapsychic structure. Acting out to reduce anxieties is a common form of denial. It is difficult for the therapist to work productively if the patient does not realize that he is externalizing when he denies that he is the "author" of the
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION 341
dream. As an example, Mr. B.'s dream in which "somebody, not me, shot my father," and "1 did not know if I had killed h i m . . . " are denials of murderous impulses. Using denial or characterological defenses, the patient initially says, "It's only a dream." Later, when associations are connected to current reality and the conflict is brought into therapy, the patient restates the situation: "It's only a dream but I am the sole author." One of the features of using the active technique described here is that the full expression of transference is averted by reflecting it away from the therapist. Usually, in brief psychotherapy, with many days between sessions, the transference is less likely to become intensified. Transference neurosis remains "free floating," while insight is actively utilized and integrated into the current life situation of the patient. Even if the therapist is made a part of the dream image, this can be most effectively utilized by generalization to some other current object having similar characteristics or playing a similar role in the life of the patient. Dream analysis in brief psychotherapy relieves symptoms and reduces acting out. It facilitates patient participation by helping him to experience disowned feelings. Dream interpretations are based on currently meaningful experiences. Dependency is avoided by therapeutic interaction which emphasizes the patient's part in creating conflict and experiencing symptoms rather than emphasizing his helplessness. Dream analysis close to the manifest level leads to active exploration of readily assimilated and currently meaningful experiences. Conclusions
Dream interpretation makes it easy to relate a patient's current problems to unconscious tendencies. In contrast with long-term analysis in which dreams become more and more distorted as they relate to a patient's resistance, it appears that workingwith the manifest dream helps the unconscious to find its way, as if a door had been opened. In other words, if the censorship of the ego is lowered through a major interest in the manifest dream content, the latent content becomes clear as it does in the dreams of children. I used to envy my colleagues who reported oedipal or preoedipal transference dreams. I felt my skills were inadequate. However, now I am concerned with discovering the patient's disturbed complexes and realizing the relative role they play in the patient's neurosis. Since I have shifted my interest in dream interpretation in order to practice more effective brief psychotherapy, I find that my patients offer me a feast of dreams. This is a great personal satisfaction. Is it possible that Freud foresaw that "the royal road" would benefit the therapist as well as the patient!
342
KOLB
References
1. Wolberg, L. R. Short-Term Psychotherapy. New York: Grune & Stratton, 1965. 2. Greenson, N. The exceptional position of dream psychoanalytic practice. Psychoanal. Q., 30: 519, 1970. 3. Gutheil, E. A. Psychoanalysis and brief psychotherapy. Clin. Psychopathol., 6(2): 207-229, 1944. 4. Freud, S. The Interpretation of Dreams, standard ed., Vol. 17. London: Hogarth Press, 1954, p. 608. 5. Merrill, S., and Cary, G. L. Dream analysis in brief psychotherapy. Am. J. Psychotherapy, 29: 185-193, 1975. 6. Stone, L.: Psychoanalysis and brief psychotherapy. Psychoanal. Q., 20: 215-237, 1951. 7. Castelnova-Tedesco, P. Brief psychotherapy. In D. X. Freedman and J. E. Dyrud (eds.), American Handbook of Psychiatry, 2nd Ed., Vol. 5. New York: Basic Books, 1975, pp. 254-268. Reprint requests to Department of Psychiatry, P.O. Box 35260, Louisville, KY, 40232.
I believe it to be true that dreams are the true interpreters of our inclinations; but there is art required to sort and understand them.
Montaigne (Essays III) The value of dream interpretation during brief psychotherapy has concerned a number of psychotherapists. Wolberg t has noted that the value of the use of dreams in therapy is dependent upon the therapist's comprehension of dynamics. Greenson2 has pointed up the significance of Gutheil's 3 observation that the dream has declined in clinical importance. He thinks that Freud's4 view of the dream as "the royal road to a knowledge of the unconscious activities of the mi nd" no longer applies. Gutheil blamed the neglect of dream material on a misconception of so-called "free association," a skillful analyst's most important tool. It should be noted, however, that with reference to dream interpretation, free association is not an issue. Associations to dreams are determined and defined by the dream content. This brings us to consideration of the following issue. In brief psychotherapy, how deeply should we penetrate or probe the unconscious, unaided by a patient's associations as possibly revealed in dreams? I think that reintroducing dream analysis into brief psychotherapy can hasten the revelation of problems and conflicts and contribute significantly to shortening the average psychotherapeutic treatment. I have found this technique to be invaluable for analytically oriented brief psychotherapy. It has been my experience that change through insight was blocked, often effectively, by resistance to self-experience. This change was quite common in students who were struggling with independence-dependence conflicts. College, and particularly graduate school, often provides a setting where feelings and values derived from the family of origin can be displaced into the school situation. My patients were all young, married medical students, acting out or fan-
Gisela E. Kolb, M.D., psychoanalyst and Instructor of Psychotherapy,University of Louisville, School of Medicine. The American Journal of Psychoanalysis © 1979 Association for the Advancement of Psychoanalysis
Vol. 39, No. 4, 1979 0002-0958/79/040335-08501.00
335
336
KOLB
tasizing fulfillment of their independence. None of them had achieved a balance between the influence of the family of origin and dependence on their parents on one hand and their ambivalent feelings toward their spouse, children, or marriage on the other. One of the most common modes of symptom presentation was almost monosymptomatic; the conflict was displaced into the context of school. To validate my hypothesis that dream analysis makes brief psychotherapy more productive, I requested my patients to relate their most recent dreams. The results are reported in the following case histories. Case 1
Mr. H., age 26, married, senior medical student, entered therapy because of examination anxieties and indecisiveness about his future specialty and where he should practice. He presented with complaints of headaches, restlessness, sleeplessness, and impairment of sexual potency. At the beginning of the second session he recalled the following dream: We were invited to a party which my wife looked forward to attending. We were leaving the house when she noticed I was wearing a light-blue suit. She asked me to change. When I refused, she elected not to attend the party with me. For clarity, the patient and I divided the dream into three parts: (I) the party invitation, (2) the light-blue suit, and (3) the reaction of the wife. Part I. During his dream associations the patient admitted that he was so involved with his studies that he rarely participated in parties. He also said that his wife complains bitterly about her isolation and his neglect of her. Part 2. With reference to the light-blue suit, he stated: "I can't imagine where this comes from. I have never had a light-blue suit." However, with i n a few minutes he recalled that when he was a little boy his family had moved into a new house. " M y mother told me that I was now old enough to have my choice of room color. I chose light blue. When my father came home he ridiculed me. He felt that light blue was a baby's color and not appropriate for an eight-year-old boy. He forced me to change my color selection." Listening to this association would tempt an experienced analyst to predict that the patient had had an argument with his father on the day prior to the dream, but the temptation was withstood and the patient continued. He recalled that his father had telephoned him early in the evening of the night he had had the dream. The father was impatient to hear his decision with regard to his career. The father favored his staying in his hometown to practice. In fact, he expected it. His father's interference had infuriated the patient. As he talked he showed great ambivalence and stated that he felt like his father was treating him as he would treat a child.
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION 337
Part 3. The patient's wife was also very angry with her father-in-law. Since she worked as a secretary to support her husband she could not understand why he was disturbed by his feelings of obligation toward his father. When the psychotherapist and the patient analyze a dream together, the dream serves as a catalyst. Merrill and Cary describe this situation: The dream serves as a catalyst in establishing sharing and accepting between patient and therapist required in effective brief analytic therapy. The dream process is actualized into experimental reality equivalent to discovery of self external reality. Interpreting dreams close to the manifest level catalyzestheir meaningful relevance to current experience both inside and outside therapy, creating a transitional phase of self-awarenessand self-acceptance,s The dream led to active exploration of the patient's particular conflict and enabled the patient and me to determine that at this critical, transitional period in his life, he had regressed to using old childhood patterns. Using only the skeleton of the latent dream content, the essential material was obtained by simplifying the manifest content. He was not referred to marital therapy, because at this point it was felt that he had to work on his submissive behavior and dependency relationship with his father in individual therapy. The oedipal situation was not touched even though it was obvious, and his ambivalent, emotional bond to his wife was not a focal point. We dealt only with the presenting problem as formalized by the dream analysis. Five individual therapy sessions revealed his relationship with his father to the patient. Emotionally free, he regained his equilibrium, decided to leave his hometown, and to live independent of his father. Case 2
Mr. B., age 27, junior medical student, entered therapy because of extreme anxiety, particularly during examination periods. He presented with insomnia and attacks of tachycardia. Primordial symptoms included: bedwetting until age 12, nail biting, and school phobia. In the first session he spoke openly about problems with his father (he was the eldest son), other authoritative figures, and competition with his brother. Although the latter was two years younger, he was in the same class in school. The patient described his father as domineering, punitive, and overly concerned about his six children. The closed boundaries prevented any of the family from having meaningful relationships outside of the family. Nevertheless, Mr. B. had married one of the first girls he had met because he wanted to get away from home. Now he felt caught in feelings of guilt. In the second session, he reported a dream he had had the previous night. "Last night I dreamed I ran and ran from one store to another in order to buy a
338
KOLB
pipe." (The phallic symbolism and the patient's struggle for his male identity are obvious. It should be noted that symbols may be meaningful to therapists; elucidating them, however, may force the patient into a dependent and passive role. Therefore, a major role of the therapist, particularly in brief psychotherapy, is to create a situation in which the patient becomes active and recognizes his or her part in creating conflicts.) Subsequently, Mr. B. reported another dream. My wife and I were standing at a lake watching a boat departing from the pier. My wife wanted to be on the boat but I tearfully, strongly refused to go and my wife was very angry. The patient associated water with swimming, his first competitive sport. He had loved it as a child. However, one day he had almost drowned, which had occasioned more attention than if he had been a winner. Afterwards, he had given up all competitive swimming and, in fact, all competition. By refusing to go with his wife, he had experienced the same emotions as he had that almost fatal day. Focusing on his passive behavior and his avoidance of competition made his conflict obvious to him. Avoidance had almost cost him his career. Two years earlier, because of examination anxieties, he had left school and had gone to work for a pharmaceutical company. There he also experienced performance difficulties; he did not trust his supervisor, a kind of displacement for the father-teacher. (It became apparent from this and subsequent dreams and the patient's associations that he had many threatening fantasies involving his father and father-authority figures.) Therefore, he had returned to medical school, where he had found himself in the same class with his brother. In one session he concluded that things would be all right if only his family would leave him alone. Thus, he began, by himself, to draw the "correct" conclusions. His observing ego was operating, and the therapist could summarize, clarify, and confront him with his situation in the classroom, where his defense mechanisms such as denial, displacement, projection, etc, could no longer protect him. He also had to deal with the onset of the symptomatology as a compromise of his neurotic conflict. He might then be motivated for certain changes in his life. The third dream reported by Mr. B. gives the full picture: I was living on the street bordering the medical school; my family lived nearby. I was carrying a radio when two guys tried to roll me. My call for help was answered by a classmate. Suddenly, I saw a lot of policemen and asked what they were doing there. Somebody told me that someone had murdered my father. I saw him lying there in a pool of blood, a note attached to his body which said: "We'll get even
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION
339
with you." I thought that the author of the note was one of the fellows who had beaten me up for the radio. I got very anxious for revenge. I told the police I would handle this by myself. I talked with my classmate and asked him to help me find the guilty party. We drove from city to city. Suddenly, I knew where to find the murderer. I knew that he used Dixie Highway. My friend and I were lying in wait on the road when he drove up. We had pistols. When his car stopped, I opened the door and there was the fe! low who had taken my radio and murdered my father. He cried and pleaded with us not to hurt him. I was trembling. I pointed my pistol, shot at him, and ran off. I did not know if l had killed him because my eyeswere closed. Working together, we broke the dream intofour segments: (1) stealing the radio, (2) the murder of the father, (3) "1'11 handle this myself," and (4) revenge. The patient had the choice of priorities in making his associations. Part 1. The radio had a significant association. "It was a Christmas gift from my father when I was 15. It was given to me at a time in my life when I started to have mixed feelings about my father." Part 2. He associated the murder of his father with his difficulties in identifying with his father. Part 3. The patient made it very clear throughout the sessions that he would pay for his therapy himself. In this session he did not follow the "rules." He did not continue by associating the fourth dream segment suggested by the therapist. Instead, he experienced independence in and outside of the therapeutic hour. He allowed himself his own stream of associations. His growing sense of independence enabled him to discuss his sexual conflicts and the way his father confronted him with this issue. During this session, he talked a great deal about him. " M y father is a real salesman. He travels a lot, drinks heavily, and probably has lots of girl friends around the country. I would give anything not to be like him but I see a lot of myself in him." At this point the patient had tears in his eyes. He was overwhelmed by his remembrances of his adolescence and regressed even further. When I was 14, I fell in love for the first time and experienced my first erection. My father found out about it and forced a separation by sending me away to a boarding camp. There, a homosexual priest made advances to me. I begged my Dad to let me come home but he was adamant that I stay. When I did return at the end of the summer, my father engaged me in a long conversation about sex. It was a ridiculous s~ion. He stumbled and stuttered and was obviously embarrassed. I was furious with him but pitied him at the same time. I had always thought of him as a very competent man. One might assume that the deeply fixated roots of this patient's conflicts required a gradual therapeutic exploration available only in long-term
340
KOLB
psychoanalysis. However, a patient's neurotic development can be arrested on whatever level the patient's pathogenic conflicts are liberated. Therapy was discontinued when the presenting problems--ambivalence toward his father and his dependency-independency conflict--became obvious in the acting out and symptomatization. In this case, the focal and remote conflicts were identical. The goal had been to enable the patient to face competition and to feel strong enough to compete with his father without frustration and anxiety stemming from the oedipal constellation. With this in mind, further regression toward homosexuality and preoedipal problems was not pursued. The patient terminated after 30 sessions. Discussion
As these cases illustrate, brief psychotherapy is valuable in dealing with cases where neurotic patterns are obvious for a long period of time. When the patient seems to have adapted through his defense mechanisms and only decompensates in certain stress situations and under most unfavorable circumstances, a brief analytic therapy might be indicated. Trial interpretation in the first one or two sessions can measure the patient's ability to reestablish a new equilibrium. In such cases, analytic theory offers the most systematic hypothesis available. Additionally, the structural aspect, id, ego, superego, operates in a dynamic way to maintain homeostasis. Disturbance in the balance of the internal structure of the personality is disruptive. Therapeutic efforts directed toward corrective specific imbalance can be effective within a short period of time. Brief psychotherapy includes focus techniques. Focus centrally defines the process of concentration, selection, and exclusion in the effort to conclude the therapy within a brief span of time. Therefore, the treatment is anchored to the present and the main objective is to relieve the patient's suffering, particularly his most stressful symptoms. To avoid regression and transference neurosis in brief psychotherapy, the analytic approach should include dream interpretation as Leo Stone, 8 Pietro Castelnovo-Tedesco, 7 and many others have emphasized. The analyst remains effective when he concentrates on the manifest content of the dream and encourages the patient to participate in the therapeutic process by focusing the basis for active change inside and outside of the therapy, alleviating symptoms and acting out of conflicts. The dream process reflects the compromising qualities of the intrapsychic structure. Acting out to reduce anxieties is a common form of denial. It is difficult for the therapist to work productively if the patient does not realize that he is externalizing when he denies that he is the "author" of the
BRIEF PSYCHOTHERAPY USING DREAM INTERPRETATION 341
dream. As an example, Mr. B.'s dream in which "somebody, not me, shot my father," and "1 did not know if I had killed h i m . . . " are denials of murderous impulses. Using denial or characterological defenses, the patient initially says, "It's only a dream." Later, when associations are connected to current reality and the conflict is brought into therapy, the patient restates the situation: "It's only a dream but I am the sole author." One of the features of using the active technique described here is that the full expression of transference is averted by reflecting it away from the therapist. Usually, in brief psychotherapy, with many days between sessions, the transference is less likely to become intensified. Transference neurosis remains "free floating," while insight is actively utilized and integrated into the current life situation of the patient. Even if the therapist is made a part of the dream image, this can be most effectively utilized by generalization to some other current object having similar characteristics or playing a similar role in the life of the patient. Dream analysis in brief psychotherapy relieves symptoms and reduces acting out. It facilitates patient participation by helping him to experience disowned feelings. Dream interpretations are based on currently meaningful experiences. Dependency is avoided by therapeutic interaction which emphasizes the patient's part in creating conflict and experiencing symptoms rather than emphasizing his helplessness. Dream analysis close to the manifest level leads to active exploration of readily assimilated and currently meaningful experiences. Conclusions
Dream interpretation makes it easy to relate a patient's current problems to unconscious tendencies. In contrast with long-term analysis in which dreams become more and more distorted as they relate to a patient's resistance, it appears that workingwith the manifest dream helps the unconscious to find its way, as if a door had been opened. In other words, if the censorship of the ego is lowered through a major interest in the manifest dream content, the latent content becomes clear as it does in the dreams of children. I used to envy my colleagues who reported oedipal or preoedipal transference dreams. I felt my skills were inadequate. However, now I am concerned with discovering the patient's disturbed complexes and realizing the relative role they play in the patient's neurosis. Since I have shifted my interest in dream interpretation in order to practice more effective brief psychotherapy, I find that my patients offer me a feast of dreams. This is a great personal satisfaction. Is it possible that Freud foresaw that "the royal road" would benefit the therapist as well as the patient!
342
KOLB
References
1. Wolberg, L. R. Short-Term Psychotherapy. New York: Grune & Stratton, 1965. 2. Greenson, N. The exceptional position of dream psychoanalytic practice. Psychoanal. Q., 30: 519, 1970. 3. Gutheil, E. A. Psychoanalysis and brief psychotherapy. Clin. Psychopathol., 6(2): 207-229, 1944. 4. Freud, S. The Interpretation of Dreams, standard ed., Vol. 17. London: Hogarth Press, 1954, p. 608. 5. Merrill, S., and Cary, G. L. Dream analysis in brief psychotherapy. Am. J. Psychotherapy, 29: 185-193, 1975. 6. Stone, L.: Psychoanalysis and brief psychotherapy. Psychoanal. Q., 20: 215-237, 1951. 7. Castelnova-Tedesco, P. Brief psychotherapy. In D. X. Freedman and J. E. Dyrud (eds.), American Handbook of Psychiatry, 2nd Ed., Vol. 5. New York: Basic Books, 1975, pp. 254-268. Reprint requests to Department of Psychiatry, P.O. Box 35260, Louisville, KY, 40232.
