Freudian Slip: Do Dreams Still Have a Role in Psychiatry

Medically Reviewed by Jacqueline Brooks, MBBCH, MRCPsych
From the WebMD Archives

March 12, 2001 -- Sigmund Freud called dreams the "royal road to the unconscious," but in many circles his ideas are as fashionable today as high-button shoes, corsets, and the turkey trot.

Scratch a psychiatrist today, and you'll more likely find under the surface someone who believes dreams are not a "royal road" but a blind alley filled with the randomly discarded trash of a day's experience.

On one side of the aisle are psychotherapists, many of whom believe dreams are a key to unlocking and liberating repressed memories of past traumatic experiences. On the other side are neurobiologists, many of whom hold that dreams are just byproducts of electrical activity -- random firing of brain circuits during sleep that cause bizarre images and weird associations.

As J. Allan Hobson, MD, professor of psychiatry at Harvard Medical School, told WebMD in an interview last year, dreams are essentially a form of delirium.

"You have visual hallucinations, you have memory loss, disorientation, ... confabulation; that's delirium by definition," he said.

But maybe, says psychiatrist Morton Reiser, MD, in an article in the March issue of the American Journal of Psychiatry, dreams are neither totally random and meaningless nor the answers to all the mysteries of the soul -- but rather a middle path between the acolytes of the brain (biologists) and the high priests of the mind (psychoanalysts).

"The place of the dream in psychiatry is shifting toward a more interesting and prominent position than it occupied in recent years, when we were being urged to regard it as a byproduct of brain stem physiology without intrinsic psychological significance," writes Reiser, MD, who is professor emeritus of psychiatry at Yale University in New Haven, Conn.

With the availability of sophisticated brain imaging techniques and improved understanding of what goes on in the brain during sleep, dreams have become "an ideal subject for experimental exploration of the relationship between mind and brain, which has always been an issue of central importance in psychiatry. And, as we become increasingly appreciative of the dream as an integrated product of adaptive mind/brain functions, the therapeutic potential for working with the dream clinically should become increasingly clear," Reiser writes.

Freud set forth his theories about the importance of dreams in his landmark work The Interpretation of Dreams, published in 1900. By his own admission, Freud never could figure out what women wanted, but when it came to understanding the importance of dreams, the old boy may really have been on to something, says Reiser in an interview with WebMD.

"I think there's so much emotion about Freud one way and another, but his statement [about dreams being the royal road to the unconscious], taken in the context of 1900, wasn't so bad," he says. "I would say that even then, I don't think he meant that dreams were the only road, but that dream images can lead us to convincing memories."

Reiser contends that although Freud lacked the scientific data available today, he understood intuitively that talking about the significance of dream images through psychotherapy could lead the patient back to early traumatic memories. Freud thought that if the patient could be induced to recall repressed, painful memories -- and those memories could be aired and examined in the light of day -- they would be rendered harmless and the patient would be cured. "We no longer think that all," Reiser says.

But dreams can be used, he contends, to help a patient understand that the conflicting emotions he is currently experiencing are complicated by older, unrecognized emotions that are still meaningful, but just beyond his conscious grasp, a bit like a word at the tip of the tongue that just won't come to mind.

"In a way, [a dream] can show the patient that was then, and this is now," Reiser says. "You don't have to so terrified of offending your boss, just because you were so terrified of your father way back then."

Reiser emphasizes that dream interpretation won't cure a psychiatric disorder the way that penicillin will cure a bacterial infection. But dreams may be signposts along the road that can point the way to improvement. And here the "old school" of psychoanalysis finds itself in parallel with the "new school" of brain biology research.

"As a tool of the psychiatrist, dreams in fact probably do give you an insight into ... processes that are not readily accessible in waking," says Robert A. Stickgold, PhD, a neurophysiologist at Massachusetts Mental Health Center and assistant professor of psychiatry at Harvard Medical School, both in Boston.

Dreams are a kind of natural inkblot test, Stickgold tells WebMD. "This is the brain putting things together without intent, without design, without purpose, without understanding," he says. "It just knows that these are things that might be worthwhile for the brain to consider together, because they might help to explain something."

He says that during rapid-eye-movement (REM) sleep, the phase of sleep where dreaming occurs, there is an interruption in the flow of information out of the hippocampus -- the brain's center for learning and memory. Instead, the brain seems to be processing sporadic, disjointed images from another part of the brain, the neocortex, where fragmented visual memories, sounds, and random ideas are stored.

Stickgold likens the process of dreaming to doing a search on the world wide web: "If you do a web search and go down the list of items, the first two or three are usually spot on, more or less what you were looking for," he says. "Then there are four or five where you say, 'That's not what I was looking for, but I know why those came up.' And if you keep going down there are about 50 where you want to say, 'I didn't ask for these at all; I don't know where they came from.' The brain is just sort of futzing and doing some [formula] to try to find things that fit together, and maybe it works and maybe it doesn't."

The computer analogy is imperfect, but handy: As WebMD reported last July, Pierre Macquet, PhD, and colleagues from the Université de Liège and the Université Libre de Bruxelles, in Belgium, and Trent University in Peterborough, Ontario, say that REM sleep, hence dreams, may be a way for the brain to recall and chew over newly formed memories before filing them away in the darker recesses of the brain -- somewhat akin to programming the computer to do a file reorganization and hard-drive backup overnight.

But Carl M. Anderson, PhD, a developmental psychobiologist at McLean Hospital in Belmont, Mass., and an instructor in psychiatry at Harvard, has a more unifying vision of the role of dreams in psychiatry today. He says dreams are probably not, as some hard-core biologists contend, just random noise generated as a byproduct of brain activity, but neither are they likely to be the keys that can unlock all of the deepest mysteries of the psyche.

"Freud's work is great, but it has to be understood that it was based on 19th-century thinking, and we have a whole other perspective now. I think both [talk therapy and neurobiology] can benefit from the changes that are going on now," Anderson says in an interview with WebMD.

"The trick with using dreams in psychiatry, from my perspective, is that you have to not get lost in theory and not get lost in over-interpretation," Stickgold says. "As even Freudians would say, you just have to say, 'Tell me what the dream was, and tell me what it means to you.'"