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Night Classes

Dream interpretation for first-time healers

The New Physician November 2007
Since dreaming is correlated with intense study, you as a medical student can be expected to dream more than individuals outside academia—that is, if you can get enough sleep.

Learning to decipher your dreams can reveal unconscious conflicts you face in medical school and the nature of your true self, and can help transform medical school “nightmares” into positive, profession-affirming experiences.

When interpreting a dream, first look at how it unfolds, noting its contents. You will likely discover some of the “special effects” Dr. Sigmund Freud describes in The Interpretation of Dreams, especially condensation, displacement, repetition and wish fulfillment.

Condensation is a distillation of two or more beings or ideas from waking life into one image, frequently manifesting as a composite human being. Displacement occurs when dream content is oriented toward a feature or action unrelated to the dreamer’s waking focus of attention. Repetition entails a dream element appearing more than once—either in the same dream or in recurring dreams—in formats such as imagery, language and wordplay. Wish fulfillment discloses a wish that the dreamer unconsciously wants fulfilled. The fulfillment is sometimes expressed overtly; other times in subtle imagery.

If disregarded, these elements can lure you into psychic tumult or leave you with disturbing sensations long after awakening. Over time, these experiences are absorbed while their meaning remains unconscious, provoking self-defeating attitudes or actions, as well as unhappiness as you shuffle disagreeably from patient to patient.

But practicing dream interpretation can help you access and reinforce your true self, increasing self-awareness. And the greater your self-awareness, the better your ability to function as a confident medical student, mindful of, rather than ruled by, the hidden agenda of your unconscious.

Ultimately, you can learn to dispel the anxiety found in disturbing dreams and use the passion of exhilarating dreams to enhance your waking energy, slipping it into your scrubs pocket like a golden nugget and taking it with you on your rounds.

Unraveling the Unconscious

Ted, a fourth-year who had just completed an infectious disease elective, had this disturbing dream:

“I’m in a treatment room with the attending, and there’s a patient wearing a loose-fitting gown. Something is horribly wrong with this poor man: He has straw-like gunk in his eye sockets, completely covering his eyeballs. Sweating, he grunts intermittently, his speech basically unintelligible…. Knowing immediately what to do, I take a sponge and soapy water and scrub his back for him.

“The man is at once a patient and my paternal grandfather. I look toward the attending physician, whom I now realize is actually my father-in-law, a doctor in real life, and he nods in approval of what I am doing for this patient. Suddenly discovering that I have not been using gloves, I pull on a pair and quickly return to the work of scrubbing. Now I see that the patient is infected with some kind of parasite. As I scrub vigorously, he says, ‘That feels good.’ His words make me feel good, too.

“But when I begin washing up, feelings of fear, resentment and rage come over me, and I ask the doctor if the patient is infectious. ‘I suppose so,’ he says. As I pull a couple of brown paper towels from the dispenser, my most horrible fears are realized. There, on my right glove, I spot a little wormlike thing with a bifurcated head standing on its hindquarters and undulating slowly from side to side. The word fluke comes to mind, and I instantly see a bunch of flukes attached to my arms. Now I realize that I will become like this patient, only I will die and my family will suffer. ‘What a horrible mistake. Why didn’t somebody warn me?’ I say to myself, feeling a nauseating sensation in my gut.”

This dream’s evocative contents yielded numerous insights into Ted’s conflicting anxieties and passions. It contains two examples of condensa-tion: The attending doubles as Ted’s father–in-law. The patient combines with Ted’s paternal grandfather, who died prematurely of congestive heart failure and chronic obstructive pulmonary disease. In effect, the condensations embody themes relating to family relationships and vulnerability to illness and death.

The essential action in the dream— scrubbing the patient’s back while tragically overlooking the need to protect himself with gloves—is a display of altruism gone wrong: The “son” cares for the grandfather under the guidance of an ineffectual, neglectful attending (or father-in-law), who leaves him vulnerable. In the dream, Ted revealed, he is less concerned about transmission of illness than about looking helpful in front of his superiors, and further explained that on his clinical rotations he often felt vulnerable himself as he cared for others, especially older men who should be protecting him. The dream illuminates Ted’s emotional nakedness—the true cause of his psychic distress.

Further, Ted’s dream contains the element of repetition—multiple meanings of the word fluke. He admitted that his lack of confidence has sometimes made him wonder if he got into medical school “by some ‘fluke,”’ and would say that very word to himself.

The unconscious wish in Ted’s dream—his desire for an inner sense of goodness and productivity—is fulfilled in the washing of the patient. The positive feelings this act evokes reflect Ted’s exhilaration at helping others as a physician. To him, a true healer involves being in physical contact with a diseased body and overseeing the patient’s course of treatment, both of which are represented in his dream.

Through dream interpretation, Ted has become more cognizant of his reactions to older men and gradually has gained a healthy sense of self-protection, trust in his own judgment and the ability to take cues from his true self.

Collecting Shells

Immediately focusing on a dream’s revelations helps prevent you from forgetting them in the controlled chaos around you. Here are some guidelines for learning from your night visions:

1. Place a pen and paper near your bed before going to sleep, whether you are at home or on call in the hospital. When you wake up from a dream, write down the content as you remember it in a quick, linear way before it fades into the ether like a helium-filled thought-balloon whose string slips gently from your weakening grip.

2. Next, list the important people, objects and actions in the dream, even if you do not yet recognize their symbolic meanings.

3. Look for condensations, displacements, repetitions and wish fulfillments in the dream content, enjoying the creations of your unconscious mind as you search for the insights they provide.

4. Free-associate to the dream imagery, noting the first thought or image triggered by elements of the dream, no matter how irrelevant it may seem. For example, dreaming of a plastic speculum behind a glass showcase may at first remind you of the day you, as an art student, were asked to visually analyze a speculum as an art object, bypassing its functional aspect. This experience in turn triggers memories of your elementary school art class, rife with rubber cement “boogers” and feelings of being small, messy and uncomfortable in a smock. Then with a sudden insight that causes you to fast-forward to the present, you see a connection between the art smock and a surgical gown, concluding that the gnawing feelings you have had lately relate to apprehensions about abandoning creativity for medicine’s methodical approach.

5. Finally, ask yourself which elements, themes and resulting insights you want to hold in your waking life to strengthen your true self—which shells collected from your psychic sea you wish to keep as you see your next patient or do your next procedure.

Nightmare Do-over

Just as you can keep positive aspects from your dreams to enrich your true self, you can also dispense with elements that detract from the vision of who you would like to be. The “nightmare rehearsal technique” is a means for revisioning a frightening or unpleasant dream, weakening its power to cause anxiety or other psychic distress.

Imagine that two weeks before your OB-Gyn rotation, you have the following dream: You are in a hospital near the elevators with a group of your fellow medical students. Suddenly, a succession of large-bodied people in physical pain are wheeled quickly in their hospital beds to the center of this open area where they crash into one another. As this happens, the elevator opens and you dash inside, but when you push the black “tongue” along the side of the door to keep it open for your classmates, it cracks apart, reminding you of an unhealthy placenta.

The door then closes abruptly, pinching your stethoscope and ripping your white coat pocket, out of which falls a small address book with a disturbing image on the front: a baby with mongoloid features emerging from a birth canal, and the faces of the horrified parents. You realize you are personally responsible for this tragedy and experience self-loathing. You conclude that the birth of this child with Down’s syndrome to ill-prepared parents is somehow linked to your poor practice.

This dream recurs several times during your OB-Gyn rotation, forcing you to experience yourself as a klutz with a reverse Midas touch—holding a position of responsibility but contributing to a disastrous outcome.

To work with this dream, first implement the steps outlined earlier to determine its meaning. Then use the nightmare rehearsal technique, revising the dream positively by going back in time to the patient’s prenatal care and seeing yourself as the practitioner who performs the amniocentesis and receives the karyotyping results. You could envision finding that the chromosomes are normal and there is no Down’s syndrome, or see yourself discovering the abnormality and helping the parents cope by explaining their options.

After revising the dream in your imagination, “rehearse” the new dream sequence in your mind before bed. The new, emotionally nourishing content reflecting your conscious wish fulfillment as a physician will become absorbed into your mind, simultaneously decreasing your anxiety and enabling confidence to spring from your true self by envisioning the type of physician and healer you wish to be.

As you record and explore the possible meanings of your dreams, you’ll become aware that they are not simply visions that restore exhausted medical students until their pagers beep them back to awareness. Rather, dreams are useful tools for understanding hidden conflicts and desires, and for activating and nourishing the true self.

Dreaming of patients, hearing patients’ own dreams, or both, may draw you closer to this self.
Adapted from the forthcoming book The Mindful Medical Student: A Psychiatrist’s Guide to Staying Who You Are While Becoming Who You Want to Be. Dr. Jeremy Spiegel is a psychiatrist in Portland, Maine. His Web site is www.mindful