Using CBT to decipher dreams

Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.

Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)

We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.

We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.

When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).

Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.

To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.

Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?

We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.

Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.

Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.

Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.

Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)

We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.

We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.

When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).

Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.

To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.

Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?

We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.

Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.

Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.

Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.

Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)

We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.

We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.

When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).

Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.

To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.

Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?

We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.

Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.

Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.