Dream work in grief therapy.

Working with dreams is useful with grief and loss clients who present with dreams. Adlerian dream analysis is one-way of exploring dreams. It incorporates the life-style of the client. This case report demonstrates how Adlerian dream analysis was used with a client. Progress was noted in improved life-style once the client began to talk about her dream.

INTRODUCTION

The therapist incorporated Adlerian dream analysis[1] as a process medium while working with a client who presented with unresolved grief and loss issues. Once the client began processing various facets of the dream and their relation to her life-style, she improved. Dream exploration was found to be useful in this client.

Literature review

Adlerian theorists believe that dreams are a manifestation of a person's life-style. They are expressions of the dreamer's attitude to life and his or her unsettled reality problems.[2] The manner, in which the client behaves during the dream is perceived as representative of his/her life-style. Adlerian psychology makes much of the unity of personality as dreams “are an attempt to make a bridge between an individual's life-style and present problems.”[3] The individual only dreams of solutions that correspond to his or her life-style.[4] Through his or her dreams the dreamer seeks guidance and an easy solution for a problem in his or her life while asleep. Only the dreamer can say with any certainty what meaning his or her dream may hold (private logic).[5]

If both therapist and client do not agree with the interpretation, then the therapist is usually wrong as the reflections come from the private logic of the dreamer.[6] According to Bird.[7]

“There are two tasks to be addressed when working with dreams. The first is to help the dreamer understand his or her current situation as shown in the dream. The second is to address the issue of whether the dreamer wishes to consider making changes and whether he or she is ready to do so and then examining the choices of practical actions available.” p. 206).

The dreamer selects images and symbols appropriate to the dreamer's subjective perception that are not bound by the constraints of the logic of waking thought and common sense. Adler assumed that dreams help the individual prepare his or her future attitudes with respect to concerns in waking life.[8] The therapeutic action starts first with the desire to understand the meaning of the dreams and the consequences of behavior. Bird[7] states “I look for an interpretation that offers the client encouragement in self-valuation, self-knowledge and social contribution” (p, 211).

CASE REPORT

A 19-year-old female African-American undergraduate in a recently broken relationship presented with grief and loss issues post death of her grandfather. She was experiencing intrusive thoughts for 3-6 months, just before going to sleep. She was the primary caregiver of her grandfather and she reported that she had not processed her grief due to load of studies and other activities at the university where she was studying. She was unable to concentrate on her studies during the day and sleep at night due to recurrent dreams. She recounted a lowering of her grades in class. Client indicated that she was referred to therapy by one of her professors. She reported that she had experienced a heightened level of anxiety that led to feelings of not being in control of her happiness, which affected her ability to enjoy life. She reported that nothing was good enough for her and that she was always playing catch up. She had feelings of guilt at her inability to feel pain when others in the world die or happiness when there is a birth of a child. She reported that she knew her thoughts were irrational, but she continued to feel guilty for having them. She was motivated for therapy, never had counseling before and was confident that psychotherapy would aid her toward her problems. Discussing the dreams of the client was important in helping her deal with her unresolved grief.

HISTORY

Educational history: The client was an undergraduate student.

Psychiatric history: There was no prior history of mental illness or use of any medication. She denied suicidal or homicidal ideation, plan or intent.

Family and social history: She indicated that her sister was in therapy. She suspected that her sister had bipolar disorder and also indicated that her paternal uncle has bipolar disorder.

Psychosocial history: Her father is an electrician and her mother is a professor in a college. She reported that her family is very anxiety prone and that she is usually the stable one in the family. She said that she is the one who has to soothe her older sister or her younger brother. She is close to her younger brother and he looks up to her for his emotional cues.

Medical history: There is no reported history of any major medical condition or hospital admission.

Religious, cultural and spiritual history: She is a practicing Christian and religion is important to her. She comes from a semi-urban area.

Leisure and recreation history: She is a writer and poet.

Substance use: She indicated some alcohol use and sometimes marijuana.

Dreams

“I see myself in a room, looking at a very old man lying on a bed. He is in the fetal position. The room is completely white with no windows and one door through which I have entered. Everything in the dream is white. The first time I had this dream I am standing near the bed, looking at the person there. The third time I had this dream, I am near the door looking at the person on the bed. All times the person is curled in the fetal position.”

MENTAL STATUS

Appearance:[8] The client appeared disheveled. Her eye contact and social interaction were within normal limits. She reported a decrease in her energy levels.

Speech: Was within normal limits.

Orientation: She was oriented three times.

Mood and affect: Mood was anxious and affect was constricted.

Perceptions: Were within normal limits although she had limited insight about what was happening to her.

Thought process: There was some impairment in judgment and a change in concentration due to tiredness and her dreams.

Sleep and appetite: Sleep was disturbed, but no change in appetite was reported.

Risk assessment: There was no suicidal or homicidal intent or plan.

Assessment: She appeared to be moderately distressed and not doing well emotionally. She was somewhat satisfied and motivated with life, with low energy. She was doing fairly in class. She had some enjoyment in life and was managing well in work, nonfamilial social relationships, physical health, money management and self-management.

Diagnosis

AXIS I:[910] V 62. 82: Bereavement

AXIS II: 799. 9: Deferred

AXIS III: None

AXIS IV: Problems related to the social environment

AXIS V: 75 (on the first visit), 90 (on termination)

Treatment

Clients’ issues related to grief and loss. Her inability to express emotions seemed to have impacted her life-style. She had not understood fully her grandfather's sickness and eventual passing. The client came to the university counseling center 5 weeks before the end of the year, and so a brief counseling model was adopted. After the initial intake, the problem she wanted to work on was identified as the recurrent dream.

Short-term goals

Relaxation exercises: These exercises were demonstrated and practiced in session. They were prescribed to help reduce performance anxiety and intrusive thoughts before sleep.

Working on her dreams: The dream was broken up into its different components. Each component were taken and discussed with regard to their impact on the clients’ life-style. Every component in the room — the bed, the color of the room and persons in the room, was talked about and their relation to life-style was discussed. The client was asked to try and make the person move in bed and see what happened to her. The significance of being near the bed and being near the door was discussed.

Sleep hygiene: Goals were set and discussed with regard to inordinate television use, substance use, about late night outs and talking on the phone at night.

Time management: Was discussed with regard to her complaint of not doing as well as she expected in class. Goals were set with regard to the organization of work hours, duration of study and study methods.

Long-term goals

Building awareness of recurrence: Instances of grief and recurrence of symptoms have been noted to occur at anniversaries, birthday and special occasions. The client was educated about these possibilities and made aware of resources for the same.

Improving life-style: The client was encouraged to made changes in her daily routine, to facilitate better study, sleep and relaxation habits.

Improving work ethic: She became aware of her perfectionistic tendencies especially with regard to school work and began working on improving her sense of self-worth with regard to her academics.

DISCUSSION

The client improved from the very first session. Talking about the dream helped her process her unresolved grief issues. On termination she reported that she was much better and was no longer troubled by the dream. Client and therapist met five times. She was a highly motivated client.