Changes in dreams - the development of a dream-transformation scale in psychoanalyses with chronically depressed, early traumatized patients

ABSTRACT

As is well known, dreams are still seen as via regia to the unconscious by many psychodynamic and psychoanalytic clinicians and researchers. Therefore, this article reports on decades of efforts to understand changes in manifest dreams in psychodynamic therapies as indicators for relevant, sustaining transformations in the inner object world of patients and to use them in comparative psychotherapy outcome studies. An empirical psychotherapy study by Leuzinger-Bohleber has described the following changes in manifest dream during successful psychoanalyses: reduction of nightmares, widening of the affective spectrum, increase of successful problemsolving, fewer observer dreams and more mature object relations. These transformations are illustrated in a detailed case report of a chronically depressed, early traumatized patient of the LAC Depression Study. In the next section the results of a systematic focused literature review aiming to identify suitable instruments for the study of dreams are presented. Finally, we discuss which conclusions can be drawn for the development of a dream transformation scale capturing changes in manifest dreams in psychodynamic therapies with depressive patients. Such a scale would be an important methodological addition for future comparative psychotherapy outcome studies, since it takes into account dreams, as a genuinely psychoanalytic criterion for psychic transformations.

KEYWORDS:

• Dreams
• transformation scale
• psychodynamic psychotherapies
• depression
• trauma

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. LAC is the acronym for ‘Psychoanalytische und kognitiv-verhaltenstherapeutische Langzeittherapien bei chronischer Depression’, a multicentric therapy outcome study of psychoanalytic and cognitive-behavioral long-term psychotherapy for chronic depressed patients (see Leuzinger-Bohleber et al., 2020)

2. FRED means ´Frankfurt fmRT/EEG Depression Study’ (see, e.g., Fischmann & Leuzinger-Bohleber, 2018). It was a substudy of the LAC Study.

3. MODE stands for ‘Multilevel Outcome Study of Psychoanalyses of Chronically Depressed Patients with Early Trauma’, an international, multicentric study ongoing in Germany (Frankfurt a.M., Cologne, Giessen, Leipzig and Mainz), in Switzerland (Lausanne) and in the US (Los Angeles, San Francisco) (see, e.g., Ambresin & Leuzinger-Bohleber, in print).

4. The author of this section is M. Leuzinger-Bohleber. She has used this clinical material in other publications, including a preliminary paper for this article (Fischmann & Leuzinger-Bohleber, 2018; Leuzinger-Bohleber & Plänkers, 2019; Leuzinger-Bohleber et al., in press). The conceptual considerations have been further developed since then, but of course the dream texts are identical.

5. Of course, I (Marianne Leuzinger-Bohleber) can only summarize fragments of the psychoanalytical process. In order to make this summary a bit less arbitrary, we discussed, as mentioned above, the material in the so-called weekly ‘clinical conferences’, following the expert validation of the ‘Three level of observation model’, developed by the clinical observation group of the International Psychoanalytical Association (IPA, see, e.g., Hanly et al., 2021). My chosen focus for systematically studying transformation processes in this psychoanalysis had been the changes in the manifest and latent dreams. Of course, this does not mean that we did not follow the treatment technique described in our manual, focusing particularly on the analysis of transference/countertransference phenomena (see Leuzinger-Bohleber et al., 2022).

6. As many of the chronically depressed patients suffered from severe sleep disorders, we offered some of them the opportunity to undergo an examination in the sleep laboratory. The EEG measurements could be discussed with Prof. Volk, an expert, in order to possibly treat the disturbed sleep with the help of sleeping pills. We also included dreams in these laboratory tests. As we reported in another paper, it was clinically and conceptually very interesting to compare these laboratory dreams with the dreams of the analysands that were told in psychoanalysis (Fischmann et al., 2012).

7. The following section is a summary of two review articles in preparation by Marielle Donié and Julia Wichelmann.

8. As is well known, psychoanalysis has for decades been concerned with the question of what distinguishes successful from a less successful psychoanalyses. The work of Leuzinger-Bohleber (1989) was developed in the context of a large psychoanalytic research network at the University of Ulm in the ‘Sonderforschungsbereich 129: Psychotherapeutische Prozesse’ of the German Research Foundation (DFG), in which about one hundred scientists were involved. Leuzinger-Bohleber used computer-assisted content analysis to carry out 5 aggregated individual case studies in which the first 100 transcribed sessions of psychoanalysis were compared with the last 100 sessions. Based on a non-psychoanalytic model of cognitive processes, changes in these psychoanalyses were investigated by defining various indicators of changes in psychoanalysis. These ‘non-psychoanalytic’ indicators of therapeutic change were compared with the assessments of the treating psychoanalysts, an expert group of psychoanalysts and the patients themselves. Based on these non-psychoanalytic and psychoanalytic assessments of the ‘success’ of the psychoanalyses, two psychoanalyses were rated as ‘very successful’, two as ‘moderately successful’ and one as ‘unsuccessful’. The changes in the manifest dream content outlined in our work (decrease in nightmares, expansion of the affective spectrum, etc.) were more pronounced in the successful psychoanalyses than in the less successful ones. They were not observed in the unsuccessful treatment.

This study can therefore be regarded as an initial step of validating the dimensions of change in the manifest dream content (see, e.g., Leuzinger-Bohleber & Kächele, 1988).

We would also like to mention that in the extensive empirical study, Leuzinger-Bohleber also discussed the central problem of whether the changes in the manifest dream contents can really contain indicators of changes in unconscious conflicts and fantasies, or whether the associations of the analysands are always needed in order to recognize the latent meanings of the dreams. There is now extensive psychoanalytic literature on this subject (see, e.g., Moser & Hortig, 2019; Weinstein et al., 2012).

9. These are preliminary results of a review. The data analysis has not yet been completed. Twenty-one studies were included. However, it should be noted that some of the studies overlapped concerning patients and selected dreams. Searches have been conducted so far in data bases as PubMed, PsycInfo, Pep Web, and meta-engines as Google Scholar. Search criteria according to the PICo criteria were changes in dreams (Phenomenon of Interest) in adult patients with depression or trauma diagnosis (Population) during the course of psychotherapeutic treatment (Context). Studies looking at the direct treatment of nightmares or nightmare disorders were excluded.

10. MAXQDA is a software of the company VERBI, with which qualitative data, such as text and audio material, can be analyzed computer-aided with focus on content categories.

11. Frightening dreams are to be distinguished from post-traumatic nightmares, for which it had not yet been conclusively clarified whether they are dreams or flashbacks/screen memories.

12. Clinician-rated assessments can be used to make assessments of narrative material. The instrument includes eight dimensions that are rated using a seven-point Likert scale, with lower scores indicating more pathological aspects of object representations and higher scores indicating more mature and adaptive functioning. Underlying this dimensional approach is the notion that personality organization is located on a continuum from maladaptive/primitive to adaptive/mature. A majority of the dimensions can be related to developmental psychological aspects (Stein & Slavin-Mulford, 2017).

Additional information

Notes on contributors

Marianne Leuzinger-Bohleber

Marianne Leuzinger-Bohleber, Prof. Dr. phil, director in charge of the Sigmund-Freud-Institut in Frankfurt a.M., Germany (2001-2016), professor em. for psychoanalysis at the University of Kassel, senior professor at the Universitymedicine in Mainz. She is training analyst of the German Psychoanalytical Association (DPV) and the International Psychoanalytical Association (IPA). Chair of the Research Subcommittees for Clinical, Conceptual, Epistemiological and Historical Research of the IPA (2001-2009), Vice Chair for Europe of the Reseach Board der IPA 2010-2021; Chair of the IPA Subcommittee for Migration and Refugees 2018/19. Since then member of the committee. She received the Mary Sigourney Award 2016, the Haskell Norman Prize for Excellence in Psychoanalysis 2017, the Robert S. Wallerstein Fellowship (2022-2027)and the IPA’s Outstanding Scientific Achievement Award, 2023 Her research fields are clinical and extraclinical research in psychoanalysis, psychoanalytical developmental research, prevention studies, interdisciplinary dialogue between psychoanalysis and literature, educational sciences and the neurosciences.

Marielle Donié

Marielle Donié, Clinical Psychologist, Doctoral Student in the MODE Study.

Julia Wichelmann

Julia Wichelmann, Clinical Psychologist, Dpctoral Student in the MODE Study.

Gilles Ambresin

Gilles Ambresin is senior lecturer and Privat-Docent at the Faculty of Biology and Medicine, Lausanne University Hospital. He is an associate member of the Swiss Psychoanalytic Society [email protected].

Tamara Fischmann

Tamara Fischmann is professor for Clinical Psychology at the International Psychoanalytic University (IPU) Berlin, Psychoanalyst (DPV/IPA) in private practice in Frankfurt a.M.