How is it that the interpretation of dreams continues to have a place in modern psychotherapy? The answer lies as much in the politics of therapy as in the popular fascination that dreams hold.
Sigmund Freud, in an introductory note to his 1900 book The Interpretation of Dreams made this overblown claim:
…the physician who cannot explain the origin of dream-images will strive in vain to understand the phobias and the obsessive and delusional ideas, or to influence them by therapeutic methods.
While most present day therapists would regard that as utter drivel, Freud’s ideas and methods still have some hold, and this includes his ideas about dreams. (I described some modern ideas about dreams a few months ago in Dreaming.)
Through it’s quango, Skills for Health, the UK government commissioned a definition of the ‘competences’ required by psychoanalysts and psychodynamic therapists. It’s not clear why they use the term ‘competences’ or sometimes ‘competencies’ instead of ‘skills’. Possibly there was a feeling that the everyday word did not sound grand enough (which says something about the nature of the exercise).
So now there’s a semi-official document specifying what psychoanalysts should be able to do: The competences required to deliver effective Psychoanalytic/ Psychodynamic Therapy (dated August 2008)
(A companion document, Psychodynamic Therapy: What skills can service users expect their therapists to have?, is much less interesting.)
Of course the competences include interpreting dreams (p. 19):
The ability to work with unconscious communication underpins the next two areas of competence, namely facilitating the exploration of unconscious feelings and of the unconscious dynamics influencing relationships…
The primary means of unconscious communication are the client’s narratives, dreams and their free associations (the spontaneous links they make between ideas).
There’s something odd, though, about this picture of psychodynamic therapy, something weirdly client-centred, or even (dare I say) CBT-ish. It includes things that psychodynamic therapists have infamously tended to resist doing.
For one thing, there’s a requirement for openness about the nature and goals of therapy (p. 17):
In order to engage, the client needs to have enough information to make an informed decision about their treatment and to feel that the therapist is willing to discuss this openly with them. It is therefore important that the therapist provides the client with direct information about the approach, including its potential risks.
The client will also require a sense of what the therapy can help them with. An important task at this early stage involves working together with the client to identify and agree therapeutic aims. This is particularly important when working within a time-limited frame, because a focus that is felt to be meaningful to the client is more likely to promote engagement.
So often, in psychodynamic therapy, therapists have in the past concealed information from patients about how the therapy really works and what its effects, both good and bad, are likely to be.
For another thing, there’s a surprising emphasis on shared understanding of the patient’s difficulties (p. 18, original emphasis):
The ability to formulate is fundamental to the practice of psychoanalytic/ psychodynamic therapy. A formulation accounts for the developmental origins of the client’s difficulties, the underlying unconscious conflicts, the defences associated with their management and the recurring interpersonal patterns and expectations of others. Clients will have areas where they show a good capacity for functioning as well as areas in which they are vulnerable or have difficulties (i.e. areas of deficit and of conflict), and formulations need to reflect this balance.
A formulation helps to bridge theory and practice, and helps ensure that therapy is mapped to the needs of the individual client. Because it is usually shared with the client it gives them a chance to conceptualise their own difficulties, and a chance to appraise the degree of fit between the formulation and their own experiences. If the formulation does not feel right to the client it can be discussed and, if appropriate, revised. This process is important because if it makes sense to the client they are more likely to be engaged with therapy.
So often, in psychodynamic therapy, therapists have in the past left their patients to do all the intellectual work, refusing to participate in any kind of formulation. And if the intellectual work never gets done because of that, the therapy just goes nowhere, in the worst cases for many years.
Comparisons with CBT
Psychodynamic therapy is still not CBT. The theory on which it is based remains exceptionally difficult to apply, with the result that relatively few psychodynamic therapists reach the level of skill needed to work with patients efficiently and effectively. One of CBT’s great strengths in practice is that it is basically simple, so that many more CBT therapists are able to achieve a high level of skill.
Also, psychodynamic therapy still lacks any effective model of healing. The competences model, just like a typical course of therapy, jumps from essentially diagnostic techniques for understanding the nature of the patient’s problem, to termination of therapy.
Unsurprisingly, the ending of psychodynamic therapy is often difficult to manage because therapy has to end before healing has taken place. CBT, in contrast, moves from formulation to a treatment plan, and it is far more likely to achieve a natural sense of closure.
It appears that pressure from CBT’s success in the NHS is forcing change on psychodynamic therapists. If the requirements of these new competences are applied with vigour, some psychodynamic therapists will find themselves having to learn new approaches, and others will not survive.
It seems likely that the interpretation of dreams will not last long as an NHS procedure in an NHS that demands tangible results, but for the moment it still gets a mention.