Psychoanalytic Psychology

2008, Vol. 25, No. 4, 565573

Copyright 2008 by the American Psychological Association

0736-9735/08/$12.00 DOI: 10.1037/a0013539

WORKING WITH DREAMS IN

PSYCHOTHERAPY
What Do Psychoanalytic Therapists Report That
They Do?
Clara E. Hill, PhD,
Jingqing Liu, MA,
Patricia Spangler, MA, and
Wonjin Sim, MA

Michele Schottenbauer, PhD

Catholic University of America

University of Maryland
Forty-seven psychoanalytic therapists completed a questionnaire about dream
work. Overall, results indicated that therapists had very positive attitudes toward
dreams, worked with their own dreams, sought out dream training, and felt
competent working with dreams. Therapists estimated that they worked with
dreams with about half of their clients about half of the time in psychotherapy.
They were most willing to work with dreams when clients had recurrent or
troubling dreams or nightmares, were psychologically minded, were seeking
growth, were interested in dreams, and were willing to work with dreams.
Keywords: dream work, attitudes toward dreams, dream training, dreams in
psychotherapy
Dreams have had a central function in psychoanalytic thinking and psychoanalytic
psychotherapy from the beginning. In the Preface to the First Edition of The Interpretation
of Dreams, Freud (1900) wrote, Anyone who has failed to explain the origin of
dream-images can scarcely hope to understand phobias, obsessions or delusions or to
bring a therapeutic influence to bear on them (p. xxiii). Since these early days, when
Freud first recognized the utility of dream interpretation in gaining understanding of the
unconscious, psychoanalytic psychotherapists have considered dream work to be a key
component of psychotherapy.
Despite the importance of dreams for psychoanalytic psychotherapy, minimal empirical research has been conducted to determine how dreams are used in psychoanalytic

Clara E. Hill, PhD, Jingqing Liu, MA, Patricia Spangler, MA, and Wonjin Sim, MA, Department
of Psychology, University of Maryland; Michele Schottenbauer, PhD, Department of Psychology,
Catholic University of America.
We thank the Consortium for Psychoanalytic Research in Washington, D.C. for allowing us to
collect data.
Correspondence concerning this article should be addressed to Clara E. Hill, PhD, Department
of Psychology, University of Maryland, College Park, MD 20742. E-mail: hill@psyc.umd.edu

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psychotherapy. In fact, we found only one empirical study on the use of dreams in
psychoanalytic practice. In this study, Lempen and Midgley (2006) used a combination of
surveys and interviews to examine the use of dreams in practice by child therapists at the
Anna Freud Centre in London. Therapists indicated that it is sometimes important to work
with dreams but not always, with more experienced therapists attaching more importance
to working with dreams than did inexperienced therapists. Most therapists did not suggest
to children in sessions that they should work with dreams. The authors suggested that the
decrease in focusing on dreams is due to a shift away from focusing on the unconscious.
Similarly, we found only three studies, all using survey methodology, that examined
the use of dreams in theoretically diverse samples. Keller et al. (1995) surveyed 228 (61%
male, 39% female) members of the Florida Psychological Association (62% had been in
practice more than 11 years; theoretical orientation was not reported). They found that
83% of participants worked with dreams in therapy at least occasionally, mostly using
Freudian and Gestalt techniques. According to the authors, many participants did not
introduce or discuss dreams unless clients took the initiative.
Schredl, Bohusch, Kahl, Mader, and Somesan (2000) surveyed 79 experienced German therapists in independent practice. About half of participants had completed psychoanalytic training; the other half were client-centered, cognitive behavioral, family, gestalt, or psychodramatic in orientation. In the total sample, therapists reported working
with dreams on average in 28% of their sessions and that an average of 49% of their clients
had worked with at least one dream. Therapists estimated that the working on dreams in
treatment significantly contributed to the success of treatment (i.e., they estimated that
70% of clients had benefited from working with dreams).
Schredl et al. (2000) also compared the psychoanalytic therapists with therapists who
were not predominantly psychoanalytic. Psychoanalytic therapists reported working on
dreams more in therapy sessions (44% vs. 15%), indicated that more of their clients had
worked with at least one dream in therapy (63% vs. 36%), and reported that they
regarded dream work as beneficial in therapy more often (M 3.23, SD 0.78 vs.
M 2.21, SD 0.78 on a 0 to 4 scale in which 4 [high]) than did the other therapists.
Furthermore, although dream recall per month was about the same (M 4.53,
SD 1.05 vs. M 4.33, SD 0.93), psychoanalytic therapists worked with their own
dreams more times per month (M 3.82, SD 1.43 vs. M 2.82, SD 1.43) than
did the other therapists.
Crook and Hill (2003) gathered more specific data about activities used by psychotherapists when working with dreams in therapy as well as information about situations and clients
with whom they were likely to use dream work. Their therapists were from Division 42
(Independent Practice) of the American Psychological Association and were mostly White,
male, middle-aged psychologists in independent practice. With regard to therapeutic approach,
the therapists on average rated themselves as relatively eclectic but as more strongly adhering
to cognitive behavioral theory and techniques than to humanistic or psychoanalytic approaches. The therapists reported that about 25% of their clients brought dreams into therapy
and that they spent an average of 8% of their time in therapy working on dreams. Therapists
engaged in more exploratory activities (e.g., listening if clients brought in dreams, exploring
connections of dream images to waking life, asking clients to describe images in greater detail)
than insight-oriented activities (e.g., interpreting dreams in terms of past experiences, interpreting dreams according to archetypes) or action-oriented activities (e.g., suggest changes that
the client could make based on dream meaning, help client to change dreams) for working with
dreams. They were more likely to work with dreams with clients who had troubling dreams
or were interested in dream work.

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567

These four studies provide some initial exploratory information about therapists
attitudes about working with dreams in psychotherapy. Crook and Hills (2003) study, in
particular, is interesting because they gathered more specific data about activities used by
psychotherapists and information about situations and clients with whom cognitive
behaviorally oriented therapists are likely to use dreams (i.e., listen, explore images, and
look for waking life connections). By contrast, it seems likely that psychoanalytic
psychotherapists, who are typically more steeped in the tradition of dream work, might
approach working with dreams quite differently. We would expect, for example, that
given the centrality of insight in psychoanalytic psychotherapy, psychoanalytic psychotherapists would value insight-oriented activities more than would psychotherapists from
other orientations.
The current paper examined dream work among a sample of experienced psychoanalytic therapists. The purpose was to investigate how and when psychoanalytic therapists
work with dreams in therapy. Essentially, we replicated Crook and Hills (2003) study so
that we could determine whether psychotherapists who were psychoanalytically-oriented
differed from psychotherapists who were cognitive-behaviorally oriented. Because Crook
and Hill used the term client rather than patient, we used this term.

Method
Participants
Participants were 47 (37 women, 10 men; 36 European American, 1 African American, 1
Latino(a), 1 Asian American, 1 Native American, 7 not reported) practicing therapists.
Average age was 59.38 (SD 11.79) and average years of clinical experience was 21.81
(SD 13.35). Primary employment was independent practice (37), university (5), agency
(4), and not reported (1). There were 14 psychiatrists, 8 social workers, 15 PhD psychologists, 9 masters level counselors (1 not reported).
In terms of theoretical orientation, participants rated themselves on three orientations using
5-point scales ranging from 1 (low) to 5 (high). On average, participants rated themselves as
believing in and adhering 4.71 (SD 0.54) to psychoanalytic orientations, 3.50 (SD 0.44)
to humanistic orientations, and 2.91 (SD 1.19) to cognitive behavioral orientations. These
data confirm that participants were indeed psychoanalytic in orientation.

Measures
The Therapist Dream Questionnaire (Crook & Hill, 2003) was used for this study. The
first part included demographic items: gender, age, highest educational degree, race/
ethnicity, number of hours per week seeing clients in individual therapy in the past year,
number of years of clinical experience since receiving highest degree, belief in and
adherence to the theory and techniques of three theoretical orientations (psychoanalytic/
psychodynamic, humanistic/existential, behavioral/cognitive behavioral), amount of
training for working with dreams, perceived competence for working with dreams in
therapy, percentage of clients who brought dreams into therapy in the past year, best
estimate of percentage of time spent in therapy working with clients dreams, estimated
dream recall, and personal dream activities (keeping a dream journal; trying to figure out
dreams on own; talking about salient dreams with a colleague, friend, partner, or
therapist). The items about training, theoretical orientation, and personal dream activities
used a 5-point Likert scale ranging from l (low or none) to 5 (high or extensive).
Estimated dream recall was assessed using two questions. First, participants were

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HILL, LIU, SPANGLER, SIM, AND SCHOTTENBAUER

asked, During the last 2 weeks, immediately upon waking up in the morning, how often
could you recall dreaming? Participants checked one of the following eight possibilities:
every morning, just about every morning, most mornings, about every other morning,
about two mornings a week, about one morning a week, once during the 2 weeks, and not
once; the highest recall response is scored as 7 and the lowest as 0. Second, they were
asked, How often do you usually have dreams you remember? Participants checked one
of five possibilities: about every night, 2 to 3 times a week, almost once a week, 1 to 2
times a month, and less than once a month; the most frequent recall response (2 to 3 times
a week) is scored as 4 and the least frequent recall response is scored as 0. Hill et a1.
(1997) found a high correlation between the two recall items, r(360) .72, p .001, and
summed the two items (M 5.68, SD 2.69). Similarly, because the correlation between
the two recall items in the present study was .79, p .001, they were summed.
The second part of the questionnaire contained 22 items using a 5-point Likert scale
ranging from 1 (never) to 5 (frequently) to assess therapeutic dream activities (e.g., ask
client to describe images in greater detail). The third part contained 19 items using a
5-point Likert scale ranging from 1 (not likely) to 5 (very likely) to assess how likely
respondents were to work with dreams in therapy under different conditions (e.g., client
presents recurrent dreams; client presents troubling dreams or nightmares; client is willing
to work with dreams) and with different types of clients (e.g., psychologically minded
client; client with posttraumatic stress disorder; client with schizophrenia/psychoses).
The last section of the questionnaire assessed therapists attitudes toward dreams using
the Attitudes Toward DreamsRevised scale (ATDR; Hill et al., 2001), a 9-item
self-report measure using a 5-point Likert scale ranging from 1 (strongly disagree) to 5
(strongly agree). A factor analysis conducted by Hill et al. indicated a single factor
accounting for 51% of variance with all items loading .50 or higher, an internal consistency alpha of .88, and a 2-week testretest reliability of.92. An internal consistency alpha
of .71 was found for the present study.

Procedures
All therapists who attended a day-long workshop entitled Dreams in Psychotherapy: An
Integrative Approach sponsored by the Consortium for Psychoanalytic Research in
Washington, DC, were invited to participate in the study at the beginning of the workshop.
After signing a consent form, therapists completed the survey. Participants were asked to
place a code number on their surveys to protect confidentiality. All 52 participants who
attended the workshop completed the survey, but 5 surveys were incomplete, yielding a
final sample of 47.

Results and Discussion

Personal and Professional Background Related
to Dreams
On the ATDR, the therapists scored 4.72 (SD 0.33). To compare these data to previous
studies using the same measures, effect sizes were calculated by dividing the difference
between the means by the averaged standard deviation (d .8 large effect; .50 to .79
medium effect; .20 to .49 small effect; Cohen, 1988). These therapists scored much
higher on the ATDR than undergraduates who volunteered to be clients in dream
sessions (M 3.66, SD 0.80, d 1.88; Hill et al., 2001) or the more cognitive
behavioral therapists in the Crook and Hill (2003) study (M 3.88, SD 0.83, d 1.33).

PSYCHOANALYTIC THERAPIST WORKING WITH DREAMS

569

In addition, these therapists were higher than those in the Crook and Hill (2003)
sample in estimated dream recall (M 6.09, SD 2.09 vs. M 5.31, SD 2.95, d
.31), were more likely to keep a dream journal (M 2.51, SD 1.67 vs. M 1.31,
SD 0.70, d .94), to try to figure out dreams on their own (M 4.51, SD 0.72 vs.
M 3.37, SD 1.30, d 1.08), and to talk about their dreams with others (M 3.66,
SD 1.26 vs. M 2.79, SD 1.23, d .70). We cannot compare the estimates directly
with Schredl et al. (2000) because different measures were used, but these results are
similar to their findings that German psychoanalytic therapists worked with their own
dreams more often than did nonpsychoanalytic therapists, although Schredl et al. found no
differences between groups on dream recall.
Thus, the psychoanalytic therapists in the current study valued their dreams and had
a rich personal dream life. We speculate that these therapists were drawn to a psychoanalytic orientation at least partially because of their personal beliefs about dreams. In
addition, it is likely that psychoanalytic training encouraged therapists to pay attention to
their dreams.

Use of Dreams in Therapy

In comparison with the therapists from more cognitive behavioral orientations in the
Crook and Hill (2003) study, these therapists felt competent about working with dreams
in therapy (M 3.68, SD 1.22 vs. M 2.88, SD 1.19, d .66), and had participated
in more training related to working with dreams (M 3.61, SD 1.44 vs. M 2.59,
SD 1.13, d .79). In addition, a higher proportion of their clients discussed dreams in
therapy (M .53, SD .31 vs. M .25, SD .25, d .99), and they spent a higher
proportion of time in therapy with clients working on dreams than did the Crook and Hill
therapists (M .24, SD .20, vs. M .08, SD .07, d 1.07). These findings are also
similar to Schredl et al.s (2000) findings that German psychoanalytic therapists worked
more with dreams with their clients than did nonpsychoanalytic therapists. These results
make sense given the emphasis in psychoanalytic theory about the importance of dreams.

Activities Used to Work With Dreams in Psychotherapy

When interpreting the results for items that used 5-point Likert scales, we followed the
guidelines used by Crook and Hill (2003): any mean 3.5 indicated high endorsement;
any mean between 2.5 and 3.49 indicated moderate endorsement; and any mean 2.49
indicated low endorsement of the item by participants.
Table 1 shows the endorsement of the 21 activities. Therapists highly endorsed 12
activities: listening if clients bring in dreams, encouraging associations to dream images,
collaborating with clients to construct a meaning of the dream, working with conflicts
represented in dreams, interpreting dreams in terms of current waking life experiences,
asking clients to describe dream images in greater detail interpreting dreams in terms of
past experiences, exploring connections of dream images to waking life, inviting clients
to tell dreams, encouraging clients to re-experience feelings in dreams, using dream
images as metaphors later in therapy, and mentioning willingness to work with dreams.
They moderately endorsed 4 activities: interpreting dreams in terms of the therapy
relationship, explaining how one works with dreams, interpreting according to unconscious wishes, and working with clients to develop ideas for change. Five activities were
endorsed infrequently: interpreting dreams according to archetypes, interpreting dreams in
spiritual terms, suggesting changes clients could make based on dream learning, asking
clients to act out different parts of dreams, and helping clients change dreams.

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HILL, LIU, SPANGLER, SIM, AND SCHOTTENBAUER

Table 1
Activities That Psychoanalytic Psychotherapists Use for Working With Dreams
in Psychotherapy
High endorsement
Listen if client brings in dreams
Encourage client to associate to dream images
Collaborate with client to construct a meaning of dream
Work with conflicts represented in dreams
Interpret dreams in terms of current waking life
Ask clients to describe dream images in greater detail
Interpret dreams in terms of past experiences
Explore connections of dream images to waking life
Invite clients to tell dreams
Encourage clients to re
Use dream images as metaphors later in therapy
Mention that you are willing to work with dreams
Moderate endorsement
Interpret dreams in terms of the therapy relationship
Explain how one works with dreams
Interpret dreams according to unconscious wishes
Work with client to develop ideas for making changes
Low endorsement
Interpret dreams according to archetypes
Interpret dreams in spiritual terms
Suggest changes based on dream learning
Ask client to act out different parts of dreams
Help clients to change dreams

SD

4.81
4.49
4.26
4.15
4.02
3.98
3.96
3.87
3.79
3.76
3.74
3.68

0.50
1.02
1.03
0.96
1.03
1.20
1.06
1.23
1.27
1.31
1.11
1.42

3.27
3.17
2.91
2.76

1.19
1.51
1.13
1.34

2.38
2.33
2.32
2.06
1.65

1.51
1.14
1.20
1.29
1.02

Note. N 47. High scores indicate high levels on all variables. All variables used a 5-point scale ranging
from 1 (low) to 5 (high); means 3.5 indicate high endorsement, means from 2.5 to 3.49 indicate moderate
endorsement, means 2.49 indicate low endorsement.

More interesting, the most highly endorsed item (Listen if clients bring in dreams)
was highly endorsed by everyone (M 4.81, SD .50). Similarly, in the Crook and Hill
(2003) sample the most strongly endorsed item was listening if clients bring in dreams
(M 4.43, SD .98). These results suggest that this activity is consistent across
therapists, regardless of orientation. Apparently, it just makes good sense to listen if
clients bring in dreams.
In contrast, there was far more variation for all the rest of the items (SD ranged from
.96 to 1.51) for this sample. Thus, for example, there was a wide range of endorsement for
items about whether therapists explained how they worked with dreams or whether they
interpreted dreams according to archetypes. The great variation in the endorsement of
most items suggests that although the psychoanalytic therapists as a group valued dreams,
they varied considerably in how they worked with dreams, which is consistent with
Lempen and Midgleys (2006) findings.
Therapists in the current study endorsed 12 of the 21 dream activities more strongly
(at least a medium effect size) than did those in the Crook and Hill (2003) sample. In
particular, in comparison with the Crook and Hill sample, they more often mentioned that
they were willing to work with dreams, encouraged clients to associate to dream images,
invited clients to tell dreams, interpreted dreams in terms of past experiences, interpreted

PSYCHOANALYTIC THERAPIST WORKING WITH DREAMS

571

dreams in terms of the therapy relationship, used dream images as metaphors later in
therapy, worked with conflicts represented in dreams, interpreted dreams in terms of
current waking life, collaborated with clients to construct a meaning of the dream,
explained how they work with dreams, interpret dreams according to archetypes, and
interpret dreams according to unconscious wishes. More interesting, all of these activities
are exploratory or insight oriented whereas none are action oriented or problem solving,
which is consistent with psychoanalytic dream work in terms of helping clients explore
and gain insight rather than engaging in problem solving (e.g., Lippmann, 2000).
No differences were found between this sample and the Crook and Hill (2003) sample
on the item Explore connections of dream images to waking life. This item was the
second most highly endorsed activity for the Crook and Hill sample and was a highly
endorsed item in the present sample. Again, this suggests that most therapists, regardless
of orientation, agree that it is important to explore connections to waking life. More
interesting, there was more discrepancy on the item Interpret dreams in terms of current
waking life, with the current sample strongly endorsing it but the Hill and Crook sample
only moderately endorsing it. It appears that the more cognitive behavioral therapists
were willing to explore dreams in terms of waking life but not to interpret them.
Across both samples, four items were strongly endorsed: listen if the client brings in
dreams, collaborate with the client to construct a meaning of the dream, ask the client to
describe dream images in greater detail, and explore connections of dream images to
waking life. These data give some idea about what therapists from a range of orientations
agree is helpful in working with dreams.
In contrast, four items received low endorsements from both samples: interpret dream
in spiritual terms, suggest changes based on dream learning, ask client to act out different
parts of dreams, and help clients try to change dreams. Experienced therapists across
orientations, then, are less likely to use these activities.

Likelihood of Working With Dreams in Various

Situations and With Various Clients
These psychoanalytic therapists reported (see Table 2) that they would be very likely to
work with dreams when clients present recurrent dreams, are psychologically minded, are
seeking growth, have troubling dreams or nightmares, are interested in learning about
dreams, have recurrent dreams, are interested in working with dreams, have an adjustment
disorder, have depression/anxiety, present a pleasant dream, have posttraumatic stress
disorder, have a personality disorder, or have a substance abuse problem. In addition, they
reported they would be likely to work with dreams when they have plenty of time in
long-term therapy or when there are impasses in therapy. In contrast, they indicated they
would be only moderately likely to work with dreams when clients use dreams to avoid
important life issues, when clients are not psychologically minded, or when clients have
schizophrenia or psychosis. More interesting, there were no clients or situations in which
these therapists were not likely to work with dreams!
It is also interesting to note that the standard deviations for the first six items (clients
present recurrent dreams, are psychologically minded, are seeking growth, have troubling
dreams or nightmares, are interested in learning about dreams, and have recurrent dreams)
were about half the size as the standard deviations for the remaining items. These data indicate
that not only were these six items highly endorsed, but there was a lot of agreement among
therapists that dreams were useful with these types of clients and situations.
A comparison of these data with the Crook and Hill (2003) data, using the same effect

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HILL, LIU, SPANGLER, SIM, AND SCHOTTENBAUER

Table 2
Likelihood of Psychoanalytically Oriented Psychotherapists Working With Dreams in
Different Situations and With Different Types of Clients
High endorsement
Client presents recurrent dreams
Psychologically minded client
Healthy client seeking growth
Client presents troubling dreams or nightmares
Client is interested in learning about his/her dreams
Client with recurrent nightmares
Client is willing to work with dreams
Client with adjustment disorder
Client with depression/anxiety
Client presents a pleasant dream
Client with posttraumatic stress disorder
Have plenty of time in long-term therapy
Client with personality disorder
At an impasse in therapy or stuck
Client with substance abuse problem
Moderate endorsement
Dream is an avoidance of important life issues
Not psychologically minded client
Client with schizophrenia/psychosis

SD

4.76
4.74
4.68
4.66
4.55
4.52
4.45
4.45
4.43
4.31
4.20
4.07
4.04
3.80
3.59

0.54
0.49
0.66
0.60
0.65
0.65
0.93
0.77
0.75
0.85
0.93
1.32
1.06
1.29
1.35

3.49
3.30
2.70

1.25
1.30
1.44

Note. N 47. High scores indicate high levels on all variables. All variables used a 5-point scale ranging
from 1 (low) to 5 (high); means 3.5 indicate high endorsement, means from 2.5 to 3.49 indicate moderate
endorsement, means 2.49 indicate low endorsement.

size analysis as indicated above, indicates that these psychoanalytic therapists were more
likely than the more cognitive behavioral therapists to work with dreams in each of the 18
instances representing different clients and situations that arise in therapy. Hence, these
psychoanalytic therapists were likely across all situations to view dream work as beneficial, perhaps because of their personal and professional experiences using it extensively.

Conclusions
These experienced psychoanalytic therapists who attended a workshop on dreams were very
enthusiastic about dreams and working with dreams in therapy. They had extremely positive
attitudes toward dreams, worked extensively on their own dreams, sought out training for
working with dreams, and felt competent about working with dreams in therapy with clients.
These data are particularly striking when comparing their data with the samples of therapists
who were less psychoanalytic in orientation (Crook & Hill, 2003; Schredl et al., 2000). In
addition, therapists in the current sample used many exploratory and insight (but not action)
activities in working with dreams and believed that dreams were useful with a wide variety of
clients (particularly clients with recurrent or troubling dreams/nightmares and with clients who
were psychologically minded and eager to work with dreams).
Limitations of the present study include the small sample size. In addition, the
therapists were all participants in a psychoanalytic-sponsored workshop on the use of
dreams in psychotherapy, so they may have been more motivated to work with dreams

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573

than other psychoanalytic therapists. Finally, therapists completed the questionnaire based
on attitudes toward working with dreams in general and recall of previous experiences in
working with dreams thus may not have accurately represented their actual work with
dreams with clients in psychotherapy sessions.
In addition, it is important to note that members of the psychoanalytic community are
quite diverse in their attitudes toward dreams (as is indicated by the large standard
deviations for many items). Thus, for example, Jungian therapists probably have very
different ways of working with dreams than self psychologists or classical Freudian
analysts. Unfortunately, we did not gather information about orientations within psychoanalytic thinking, so we do not know how many different types were represented.
The implication of these findings is that there is some convergence among therapists
in general about effective activities (listen, collaborate in meaning making, ask for
description of images, explore connections to waking life) for working with dreams.
Similarly, there is convergence that it is valuable to work with dreams with clients who
have recurrent dreams, troubling dreams, or nightmares and also when clients are psychologically minded, seeking growth, and are interested in dreams.
In terms of implications for research, we suggest that it would be interesting to
replicate these findings with subgroups of psychoanalytic therapists (i.e., Freudian, Jungian,
self-psychologists, objects relations) to determine differences among subtypes of psychoanalytic practitioners. In addition, we recommend that researchers take this research a step
further and investigate how therapists actually work with dreams in ongoing therapy.
Researchers could examine videotapes of dream sessions or ask therapists and clients
immediately after sessions to report on what activities were used.

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