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Sleep Tight: Working Creatively with Dreams in CAT

Coulter, N. and Rushbrook, Dr S., 2012. Sleep Tight: Working Creatively with Dreams in CAT. Reformulation, Summer, pp.7-12.

Introduction

This paper presents a technique based on Fritz Perls’ approach to dream analysis and how we have incorporated this into our CAT practice. According to Ryle (1991) dreams can be used in therapy as, ‘Their meaning to the patient and their relation to the therapy can be considered jointly by patient and therapist in the same way as all the other communications of the patient’. We will share how we work with dreams in CAT, demonstrating clinical practice with the aid of a case study, illustrating how this technique elegantly fits with the CAT model and CAT tasks. Our experience of using this dream work is with people who have a diagnosis of Personality Disorder (PD) and symptoms of Post Traumatic Stress Disorder (PTSD).

Theoretical background

Fritz Perls’ work was influenced by psychoanalytic and Jungian concepts.

Sigmund Freud (1856-1939) transformed the study of dreams with his work The Interpretation of Dreams. Freud analysed dreams as an opportunity to understand pathology, believing that our dreams were relevant as a means to access our unconscious, which he perceived motivated our every action and thought. Freud stated that dreams were ‘the royal road to the unconscious’. According to Freud, dreams served to process regressed urges and impulses whilst protecting the waking mind from alarming feelings and images.

Like Freud, Carl Jung (1875-1961) believed that through the analysis of the symbols in dreams, underlying meaning could be revealed. Rather than concealing hidden desires, as Freud believed, Jung perceived them to be a vehicle to communicate the unconscious to the conscious mind. Jung stipulated that every person in the dream represented an aspect of the dreamer.

Fritz Perls (1893-1970) expanded this point of view to say that even inanimate objects in the dream represent aspects of the dreamer. He perceived that a dream ‘represents different projected and disowned aspects of the personality’ (in Clarkson & Mackewn, 1993). He asserted that dreams were the most spontaneous form of expression and postulated that dreams were the most direct means to identify that which has been disavowed, rejected or suppressed. Perls argued that emotional distress stemmed from patients accepting certain aspects of their experience while projecting and dissociating others. Healing would come through the re-integration of the disowned parts, (which is compliant with CAT theory on integrating different states) and the dream is an ideal vehicle for this process. Perls described dreams as the ‘royal road to integration’ (Perls, 1969).

Basic principles of enabling recognition

Our work with dreams has drawn on the techniques described by Perls, and originates from the Gestalt tradition which Perls co-founded in the 1950s. Gestalt has developed in recent years to become increasingly relational in its approach and hence more compatible with CAT. We have not attempted to incorporate all Perls’ style and method, and further reading is recommended. In our own practice we are guided by the following principles:

The client is orientated to the dream technique and consent is elicited.
The therapist aims to work within the client’s Zone of Proximal Development (Vygotsky) by reflecting on the therapeutic relationship. It is important to facilitate opportunities for exploration, and to act with responsive flexibility to any perceived or observed subtle therapeutic ruptures which would suggest being outside of their ZPD.
The client is asked to describe the dream in detail.
Essentially, the dreamer is everything in the dream and every object in the dream represents an aspect of the self. The dreamer is the house, the wind, the pursuer and the pursued. This fits with our theoretical understanding of reciprocal roles in CAT; each person/inanimate object represents a reciprocal role; self to self, but also self to other and other to self.
Perls would ask his patients to embody these images in turn, by speaking from the perspective of each of them, in the present tense e.g. as the house: I am big; I have four windows etc. The therapist may facilitate this process by prompting them to use ‘I’ rather than ‘it’ and asking questions e.g. What can you see? What is around you? How do you feel? As the house how do you feel to have Lisa walking through your front door? This is especially useful in CAT for identifying disavowed poles of reciprocal roles. In our work, we find that people who have a diagnosis of PD often identify with one role e.g. child derived roles and disavow the parentally derived roles.
The dream is owned by the dreamer. The therapist skilfully facilitates and questions rather than presenting one’s own ideas and interpretations. Perls stated ‘you [the client] know everything; you know much more than I do and all my interpretations would only mislead you. It’s again, simply the question of learning, of uncovering your true self.’ (Perls, F. p191; 1973) This highlights the collaborative approach so integral to our CAT practice, as noted by Potter, (2004) when he suggests we avoid CAT as a process done for the client but rather done with the client.
The dream also reflects the relationship with the person who is being told the dream. This dream technique is a thoroughly dialogic act in which in the therapist’s response is integral to the creation of a unique collaboration.

Process of revision

The dream is a rich source of metaphor and it enables the dreamer to talk about experiences with some distance and so can open up a dialogue between different reciprocal roles. The dream becomes a mediating sign as this technique facilitates a method of collaboratively and curiously exploring potentially difficult and painful feelings. Since the dream is in the realm of fantasy it manages to distil down some of the abject terror associated with directly re-telling distressing experiences.

The client can enter into a creative dialogue with themselves, and with the therapist, in a playful way. When embodying a dream component, one is fantasising - playing, as if moulding playdough sculptures in the imagination. This process is accessing the creative, playful part of the self and gives rise to the ‘creative spot for change’ (Rushbrook and Coulter 2010) where change can occur in the space between therapist and client.

In being curious, the therapist challenges and facilitates a transformation of the client’s original relationship with a dream. Thus the client moves from a position of fear, shame or anger, to one of curiosity and interest. In CAT terms this means moving away from the problematic procedures and into the Observing Eye, hence losing the emotional intensity. It makes the unbearable manageable, allowing you to speak to the unspeakable, and is a potential path to integration.

Dent-Brown (2011) discusses a similar feature in his paper on the six part story method (6PSM) describing its advantages, whereby clients describe their own experience through metaphor - they are able to reflect on the metaphor without being caught up in it. Jeffries (2011) has also commented that ‘Sometimes a direct approach to the client’s own authentic feelings is too overwhelming or threatening to bear... [so if a client]...’ connects with a character going through experiences that are close to home, it can provide a way of “externalizing” feelings, and may allow a client enough safety to explore previously warded-off feelings about their own experiences’. In this way the core pain is held in the dream, so we can explore it in a safe way as it is no longer so desperately concealed.

By encouraging the client to experience, in the present moment, an aspect of the dream, it will often serve to acknowledge and realise feelings that have been disavowed ‘if you identify with these alienated parts, we can now get ready to assimilate disowned parts and grow again – become more whole’ (Perls p193). Similarly, Bristowe and Reason (2010) state that the experience needs to be ‘felt, expressed, enacted and embodied’ in order to ‘lead to different, felt consequences’: our exits in CAT.

Case illustration

Lisa completed a 24 session CAT. Dream work commenced during this time. After follow up was completed Lisa called asking for help as she had experienced a strong grief reaction following the end of the therapy. This represented an Exit that we had identified in the first therapy – asking for help. Following consultation with the team, Lisa was then offered and completed a second 24 session CAT.

Brief historical background

Lisa (name changed) had suffered a deeply traumatic and abusive past. Her mother had discovered that Lisa was being abused by her father when Lisa was three. Shortly afterwards, her mother abruptly left the family home in a seemingly blaming way as her mother shouted at her to go inside because she was ‘dirty’. Lisa did not see her mother again until she was a teenager. Given that her mother abandoned her and her father sexually abused her, it appears that she internalised these roles and re-enacted them self to self. Thus she coped with overwhelming emotions through a restricting bulimic eating disorder, promiscuity and misuse of alcohol.

We developed a state map together and looked at how she entered a cycle of abuse, in an effort to avoid being abandoned - her dreaded unimaginable horror. As a consequence of this cycle of abuse she habitually felt used and rejected. Whilst in time it was possible for her to identify herself in the bottom, child derived roles, it was far more difficult for her to see how she could be in the parentally derived roles. Feeling so utterly undeserving, and having experienced herself as if an object to serve other people, it was hard for her to imagine that what she was doing to herself, and others, was of any importance or note.

Lisa often brought dreams to therapy. For the purpose of this case study three elements have been selected to illustrate how dreams may be used in CAT.

1. Recurrent intruder dream

Lisa told me about a recurring dream that she had experienced for the majority of her adult life, some 25 years. Such was the terror of this dream that she would sleep with the light on, fear going to bed and frequently would take unknown men home, as she had noticed that she was less likely to experience her nightmare. This procedural sequence led her to re-enact the cycle of abuse she had experienced as a child as these men would have sex with her and show little kindness or compassion. She believed that she was not worthy/deserving of love, care and protection, and perceived that she was not allowed to have needs. In order to be in relation with another she felt as if she must provide something in order to keep them close and keep her nightmares at bay. Potter (2004) highlighted this position when he wrote about how the ‘difficult states [clients] experience are at one pole of a reciprocal role, the other pole of which they are dramatically engaged with by either enacting it to themselves or putting it out passively or actively for others to play’.

Lisa’s dream: Lying in bed alone I suddenly sense a man’s presence: he gets into bed with me, kicking me and I am petrified, as if turned to stone. I cannot move and I cannot speak. I want to turn around to look at him to see who it is but I dare not. I can feel his breath and his skin next to mine.

Perls encouraged exploration of the aspects of the dream that are most feared (in Clarkson & Mackewn, 1993) ‘because those often represent the parts of ourselves from which we are most alienated’. Lisa as the man/intruder: I am hiding at the bottom of the bed waiting for Lisa to go to sleep. I am touching her, feeling her. She is useless. She’s dead so I kick her out of bed. As the man, she became able to see how she treated herself. We were able to explore the self to self enactment of abusing-abused reciprocal role. The man in the dream came to hold the meaning for the part of her that was terrifying and abusive.

Lisa as the bed: I have a moving heavy weight on one side, a dead weight where Lisa is lying. The other side was moving where the man was. I (the bed) don’t want the dead weight, she is unwanted, a burden. I have no feelings for the man. She linked this to feeling as if she was a dead weight, heavy like concrete, and remembered looking in the mirror as a child and seeing herself as huge. As the bed, she experienced and embodied the part of herself that was cut off and rejecting, feeling herself to be a burden and something heavy to support, thus illustrating her abandoning to abandoned self to self reciprocal role.

Later in therapy, Lisa as the bed: I don’t want the man to be there, I want him to go. I am supporting Lisa but I am helpless to know what to do for her, I cannot move and I cannot speak. After this dream, it was poignant for Lisa to recognise for the first time that there was an aspect of herself emerging that wanted to support her. Whilst she did not know what to do to help, she was no longer abandoning. Indeed, as the bed, she had become more angry with the intruder and supportive of herself. Lisa had therefore begun to notice an exit, and started to develop a healthy role by considering the possibility of being concerned for herself - an emergence of caring to cared for reciprocal role.

Later again Lisa as the bed: I am powerful. I have springs. I want to protect Lisa from the man; my springs can shoot her up and away from him. Here she is not only noticing the exit but realising it; revision is evident.

Over time the dream slowly transformed, and as the weeks passed she started to turn to face the attacker until finally she had a dream whereby she shouted ‘NO!’ at him. This represented her improved ability, both within the dream and in her waking life, to develop boundaries and limits. Therefore she had begun to develop a protective to protecting reciprocal role.

The changes that occurred in her dreams corresponded with revised Target Problem Procedures in life, namely an increase in self care and a significant reduction in her destructive and neglectful coping strategies. For example, Lisa was in a taxi heading home with a strange man, she turned and looked at him and thus was able to stop the cab and get out saying ‘goodbye’ (thus saying ‘no’) and went home alone.

Lisa started to be able to sleep with the light off and then eventually that particular nightmare ceased altogether. Perls encouraged working with the terrifying parts of the nightmare in order to eliminate the dream ’if you are pursued by an ogre in the dream, and you become the ogre, the nightmare disappears. You re-own the energy that is invested in the demon’ Perls (1969: p164). Lisa’s relationship with these dreams changed in this way; waking and feeling fearful in the first instance, she later became more curious about what they might tell her about how she was feeling and what was happening self to self in her reciprocal roles in her dream and in the current context of her life. Therefore the exploration she had done in the therapy room had developed so she was able to do this on her own, thus improving her reflective ability independent of the therapist.

Furthermore, by exploring the abuser’s role she could step back and experience the power, anger and hatred that she felt towards herself, but had hitherto disavowed. Lisa was able to start to own her anger and develop a healthy relationship with her tentative indignation at how she had been treated and could be treated in her present life.

At one point in the therapy, after sleeping with a man she felt disgust and shame for the first time. Whilst this was painful, we looked at how this was protective as she had a congruent emotional response, as opposed to being dissociated and cut off. The function of the disgust and shame made it less likely for her to engage in such behaviour and reflected her healthy response to the improved sense of her self value.

2. Baby dream

Lisa’s dream: I have a baby that I want to care for but I can only watch helplessly as the baby is neglected.

Lisa as the baby: Everyone is very big, I am very small and I am looking in a mirror slumped; I cannot hold myself up properly. I am tired, quiet. I don’t care anymore, it has gone beyond, I have tried but it is hopeless. I am so thirsty. I am not going to cry. I am going to smile. I see something slumped in the mirror. Why am I so dead? I am trying to work it out. We discussed how this represented Lisa enacting the neglecting role self to self. In embodying the role of the baby she is able to experience a shift towards a more curious stance, in this instance in her self to self relationship. The dream work facilitates a conscious awareness of new information, literally seen from a different viewpoint that might otherwise have remained hidden.

Lisa as the mirror: I have the baby in front of me. Behind me I can see legs (people in the room). I am close to the baby, I am the only one that is connected with the baby and I want to show the baby something, I want the baby to see. I feel quite powerful as if I am the only one that can make the baby see. I see the baby as special and I want her to smile and be able to see joy for it to have some connection. The light from me is sending out a light to the baby. The baby is on her own she needs help. Other things can help it. I want the baby to lift its head up a little bit and look. Once again, taking a different viewpoint accesses a wealth of new information previously disavowed. Lisa discovered the possibility of not only desiring to offer care to the baby (herself) but also a desire to be connected with the baby. A powerful exit began to emerge here – the possibility of giving herself precious, nourishing care.

Lisa later dreamed of holding the baby in her arms, both gazing at each other. Here, in the dream the possibility of nourishing herself became her experience as she cared for the baby. The reciprocal roles in the dreams changed from ignoring, neglecting, rejecting and abusive to seeing, holding caring for and supportive of.

Lisa began to notice how therapy was holding a mirror up to her. Part of her was looking and wanting to see, but another part felt hopeless and powerless without support from others. The baby became an important mediating sign throughout our therapy, and we would often talk about how she could look after this little baby in her, what this baby needed (care, to be held, to be seen, given warmth, food and drink) and what would hurt the baby (neglect, abuse, no nourishment or sleep).

3. Transitional dream

As we approached the end of therapy Lisa brought a further dream. In the dream someone was breaking into the house, he broke and shattered the door and came to steal the purse that lay beside her bed. Later in the dream Lisa had approached the door, but found that she could not mend it and experienced a sense that there was no protection.

The dream afforded us an opportunity to explore aspects of our therapeutic relationship. For example, checking out with Lisa whether it felt as if I were breaking her and whether she could say no to me or if I was like her mother, leaving her vulnerable to abuse when her door was left broken. Lisa could name and describe some of her feelings about termination of therapy: fear of being abandoned and left unprotected. She was able to own feelings of connection to me and consequently to face the loss of our sessions, and thus our relationship, ending.

In addition, the dream work facilitated an awareness that Lisa felt as if she had broken down her own door, leaving her feeling exposed as she gave up previously destructive coping strategies and made brave attempts to improve her self-care. She was beginning to tolerate and rely on her own resources but the transitional process was understandably alarming for her. The sense of safety developed when she felt able to protect herself as she created boundaries. Discussing the elements of the dream in relation to the door facilitated recognition of her self to self enactment of original reciprocal roles and thus enabled her to identify the exit that she needed to ensure her sense of safety and protection.

Summary of revision

Lisa moved from a position of horror to one of curiosity, compassion and ultimately clarity of what she would and would not tolerate. She transformed the reciprocal role procedures of neglecting to neglected and abusing to abused, to caring to cared for and protecting to protected; she began to say no, actively demanding something different for herself. She was slowly able to recognise herself - in the mirror dream when she started to look at “the baby”. Lisa learned that she could support herself, initially when embodying “the bed”, later also viewing her engagement in therapy as an act of self support. As she progressed through the therapy she became less tolerant to enduring abuse and more insistent that she would like to be treated with care and respect both by herself and others. Also, by recognising the terror of the threat of abandonment and acknowledging how she could be abandoning of herself and others, she was able to engage in a dialogue with the part of herself that was so terrified and provide compassion and nurture to help soothe herself when she felt fearful. Here, dream work ‘can track the call and response of different voices within a state and between states.’ (Potter, 2004) Thus she was able to transform the procedure of chronic deprivation; neglecting to neglected and abusing to abused, to desiring care and protection for herself. Later, providing it for herself in realising exits.

Conclusion

This technique is helpful partly due to the non-confrontational nature of the exploration. It is not face to face, but more side by side as Potter, (2004), has described in his work. It appears to be more manageable - and within the client’s zone of proximal development. Furthermore, the dream work had afforded an opportunity to process what had previously been inaccessible as it seemed outside of conscious awareness and control.

Metaphors from dreams act as mediating signs throughout the therapy. This enables a client to turn and face what is truly terrifying in therapy, not only in their historical and present day experience, but also in the therapeutic relationship. Clients learn to be inquisitive; not to judge themselves or expect to act differently. The aim, rather, is to transform the relationship with the dream, and thus the past, from one of fear to one of curiosity within the Observing Eye.

This technique allows movement and flexibility; dancing with freedom and fluidity to hit the creative spot to facilitate change. Such skills, as with CAT generally, can be taken by the client from the therapy and used independently; ‘what the child does with an adult today she will do on her own tomorrow’ (Ryle 2001).

We have also discussed how this technique can be utilised outside of dream work. For example with the six part story method, so developing the metaphor in the client’s story to embody the aspects described, e.g. ‘I am the kite, my strings are broken...’ which may enhance the exploration of themes provided by the process of telling the story through experientially accessing a variety of perspectives. Similarly it can be used to embody such phenomena as physical or emotional pain, self harm, addiction etc. So for instance, as pain you might explore pain in relation to the client; I am powerful, big…I want to hurt/protect/envelop X. Or, as addiction: embodying the desire, the emotions, the drug, the syringe etc in turn.

This was used with Lisa to creatively explore binge eating and purging behaviours. It was illuminating and revealed previously unexplored material. Initially Lisa described the binge and then described herself as the food and the vomit in subsequent sessions. This was extremely powerful and emotionally painful but created more compassionate understanding regarding why she felt so compelled to behave in such a way. Her harsh critical voice reduced and this then enabled her to actively start to revise the procedural patterns. Using this technique with the binge and purge felt more precarious and stretched Lisa’s ZPD further as we had moved from the realms of fantasy (the dream) to a closer real-lived experience and behaviour.

These strategies serve as an effective tool that elegantly facilitates the CAT process of recognising reciprocal roles and revising problematic procedures. However, it must be noted that even when clients have appeared to collaboratively agree to work in this way, there have been times when it is evident that they have not responded openly, at some point offering resistance, and we have respectfully withdrawn and explored the process.

Overall, we have found this technique to be enormously useful, it has deepened our and our clients’ understanding of the different unconscious forces at play and has provided unique opportunities for real and enduring change.

Footnote

Lisa, who has read the article and was invited to comment, writes, “I would like to add a footnote. Thank you. I would like to talk about the way it changed my life. I was living in total fear and a prisoner to that recurring nightmare of the man climbing into bed with me. It was absolutely real. I could hear him breathing, feel him biting me and bruising me. I woke to continue to feel those bites and bruises. It affected me all day in that I was controlled and frightened of this stranger. I dreaded the evening, the night, being sleepy. I fought to keep awake, as I knew that as I succumbed to sleep, the pillow would start to lift under my head, the door open and he was waiting at the foot of the bed and would climb in behind me. I even tried to only sleep on the sofa with the TV on. I really believed nobody could help me and that this would destroy me. The gradual process of looking at the "realities" of this nightmare with someone supporting me and "holding my hand" really did save my life. I was finally able to stand up to the abuse, to turn in my bed and tell him to leave. Although in dream, this was completely real to me and as frightening as though in real, waking life. I at last realised I did not deserve abuse. The nightmare never returned and my life began to turn around. A completely empowering experience. The dream of the baby in the mirror also through working through different aspects, enabled me to care for this part of me - to start to nurture myself and look after the child. Now 10 or more years later- important dreams resonate the next day. I can feel that a certain dream is telling me something. It "bothers" me, and through using the techniques used in CAT. I find certainties and guidance. My inner self knows the truth and dreams help me access that truth, when daily life is confusing me or luring me into a path or relationship that is not healthy and may be destructive to well being”.

About the authors

Nicola Coulter is an Occupational Therapist and Dr Sophie Rushbrook is a Clinical Psychologist working in private practice and at the Intensive Psychological Therapies Service (IPTS), a Beacon service in Poole, Dorset. The service provides CAT and Dialectical Behaviour Therapy (DBT) to people with personality disorders. IPTS is part of Dorset HealthCare University NHS Foundation Trust and linked to Bournemouth University Department of Mental Health.

References

Bristow, J. and Reason, A. (2010) Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship – A Case Example. Reformulation, Summer, pp.31-33.
Clarkson, P. and Mackewn, J. (1993) Key Figures in Counselling and Psychotherapy: Fritz Perls. Sage Publications.
Dent-Brown, K. (2011) Six-Part Storymaking – a tool for CAT practitioners. Reformulation, Summer, pp.34-36.
Freud, S. (2010) The Interpretation of Dreams. The Illustrated Edition. Sterling Press.
Jacobs, L. & Hycner R., (2008) "Relational Approaches in Gestalt Therapy" (2008) Routledge, Taylor & Francis.
Jefferis, S. (2011) Memoirs, Myths and Movies: Using Books & Film in Cognitive Analytic Therapy. Reformulation, Summer, pp.29-33.
Jung, C.G. (1968) Man and His Symbols. Dell Publishing.
Perls, F. (1969) Gestalt Therapy Verbatim. Moab. UT Real People Press.
Perls, F. (1973) The Gestalt Approach & Eye Witness To Therapy. Science and Behaviour Books.
Potter, S. (2004) Untying the knots: relational states of mind in Cognitive Analytic Therapy? Reformulation. Spring, pp.14-21.
Rushbrook,S. and Coulter, N. (2010) Playfulness in CAT. Reformulation. Winter, pp.24-27.
Ryle, A. (1991) Cognitive Analytic Therapy: Active Participation in Change. A new integration in Brief Psychotherapy. Wiley Series in Psychotherapy and Counselling
Ryle, A. (2001) CAT's Dialogic Perspective on the Self. ACAT news Article
Vygotsky, L.S. (1978) Mind in society: The development of higher psychological processes. Cole, V. John-Steiner, S. Scribner, E. Souberman. (Eds.). Cambridge, MA:Harvard University Press.
A recommended read:
Jacobs, L. Hycner,R.(2008) Relational Approaches in Gestalt Therapy. Routledge,Taylor and Francis. Gestalt Press.

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Full Reference

Coulter, N. and Rushbrook, Dr S., 2012. Sleep Tight: Working Creatively with Dreams in CAT. Reformulation, Summer, pp.7-12.

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