INTRODUCTION
Oncology health professionals frequently encounter patients who complain of “poor sleep”. When analyzed, the complaint of “poor sleep” often reflects a combination of physical discomfort and a prevalence of disturbing dreams. Most of the existing literature on insomnia in cancer patients focuses on physiological measures of sleep disturbance and their effects on the patient's symptomatic status (Kvale & Shuster, Reference Kvale and Shuster2006). This article has two goals: (1) to help oncology healthcare providers understand how a patient's psychological and physical experiences of cancer become expressed in dreams; and (2) to offer these professionals methods of managing cancer patients' dream material, in order to promote the goal of facilitating more restful sleep and improved quality of life.
First, we shall briefly review the developments in dream theory and sleep science from 1900 to the present. Then we shall present examples of dreams of cancer patients, their families, and oncology nursing staff. Finally, we shall suggest pragmatic methods for understanding and intervening in troubled dreams and disturbed sleep.
REVIEW OF LITERATURE
In the past century, dream theory has progressed from the notion that dream content has absolute meaning for the dreamer (Freud, Reference Freud1900) to the opposite extreme, namely that dream imagery is random, aimless and merely a meaningless by-product of biochemical signals in the brain (Hobson & McCarley, Reference Hobson and McCarley1977). More recently, the concept has arisen that dreams serve a biologically adaptive function by simulating threatening events so that the dreamer can rehearse threat perception and threat avoidance skills (Revonsuo, Reference Revonsuo2000).
Sigmund Freud was the first scientist to attempt to comprehensively organize and create a system of interpretation for dreams. His book The Interpretation of Dreams (Freud, Reference Freud1900) represents the culmination of his efforts to create a coherent theory of dreams.
In organizing his theory of dreams, Freud distinguished between two different kinds of mental functioning: primary and secondary processes. Primary process (latent content) refers to uncensored, disorganized, raw emotion and experience, whereas secondary process (manifest content) refers to ordinary, conscious thinking that is both verbal and logical. Freud described the process of transformation from the latent to the manifest as the “dream work.” The manifest content contains those elements that are remembered upon awakening from a dream. He posited that the disturbing content in the dream work undergoes a process of censorship termed “secondary revision.” In this revision process, thoughts and impulses are transformed into a visual format organized as a “story.” In short, Freud believed that dreams were protective processes (disguises) to deal with unacceptable personal conflicts and wishes (Freud, Reference Freud1900).
Two critical discoveries in 1953 and 1962 created a turning point in the understanding of dream states. Aserinsky and Kleitman (Reference Aserinsky and Kleitman1953) first described the phenomenon of rapid eye movements (REM) during sleep cycles in children and adults. They found that REM stage sleep was associated with high brain wave activity, muscular flaccidity, and dreaming. In 1962, Jouvet discovered that electrically stimulating the pons structure in the brain stem created REM phases, and that no higher order brain structures were involved in this process. These discoveries of Azerinsky and Kleitman (Reference Aserinsky and Kleitman1953) and Jouvet (Reference Jouvet1962) cast substantial doubt on Freud's theory of dreams and introduced neuroscience as central to understanding the function of dream states in the brain.
Hobson and McCarley (Reference Hobson and McCarley1977) propelled sleep research further by proposing complementary theories of reciprocal-interaction and activation-synthesis. According to the activation-synthesis model, acetylcholine triggers arousal in the pons and limbic systems, thereby creating dream images. This theory posits that the resultant neurotransmitter-stimulated images are random and have no meaning or psychological function. This model created an uproar in clinical psychiatry and psychology because it denied that emotion was involved or causal in the creation of dreams. According to Hobson and McCarley (Reference Hobson and McCarley1977), only biochemical feedback loops caused dreams.
Nonetheless, interest in dream content persisted through this era. A particularly enduring and often cited example of this is the Hall and Van de Castle Content Analysis of Dreams (Reference Hall1966), which is a comprehensive coding system for the study of dream content. Hall and Van de Castle showed, along with others later (Hartmann, Reference Hartmann2000; Domhoff, Reference Domhoff2003; Schredl, Reference Schredl2003), that there is a continuum between waking experiences and experiences within dreams, which they termed the “continuity hypothesis” (Schredl, Reference Schredl2003). Therefore, elements of waking experience are incorporated into dreams. However, these authors concluded that this hypothesis could not predict that a single exposure to any type of event would lead to persistent, recurring, disturbing dreams.
Threat simulation theory (TST) attempted to utilize some elements of the continuity hypothesis (Hobson & McCarley, Reference Hobson and McCarley1977; Revonsuo, Reference Revonsuo2000; Valli et al., Reference Valli, Revonsuo and Paikas2005). Revonsuo argued that (1) dream content is neither disorganized nor a random by-product of REM physiology; (2) the brain constructs a complex model of the world in which certain elements are over-represented and others are under-represented; (3) dream content is consistently and powerfully modulated by certain types of waking experiences; and (4) the biological function of dreaming is to simulate threatening events and enable the dreamer to rehearse threat perception and threat avoidance (Valli et al., Reference Valli, Revonsuo and Paikas2005).
Valli and colleagues (Reference Valli, Revonsuo and Paikas2005) systematically examined the hypothesis, based on TST, that real, threatening events occurring during the waking state should lead to an increased activation of the threat simulation system and the threat simulation response. Such increased activation should result in an increased frequency and severity of threatening events in dreams. They tested this hypothesis on several populations of children, including Kurdish children and adolescents and Finnish children. The Kurdish children lived in Iraqi Kurdistan and had often witnessed warfare and family deaths. It turned out that the Kurdish children had significantly activated dream production and threat simulation systems when compared with the population of Finnish children who lived in Finland (Valli et al., Reference Valli, Revonsuo and Paikas2005).
Approximately 5% of adults in the general adult United States population report nightmares (Bixler et al., Reference Bixler, Kales and Soldatos1979). In a field trial of adult subjects suffering from post-traumatic stress disorder (PTSD), the incidence of post-traumatic nightmares during the preceding 6 months was 61% (Kilpatrick et al., Reference Kilpatrick, Resnick, Freedy, Widiger, Frances and Pincus1998). Individuals with PTSD have nightmares in REM as well as in non-REM sleep (Wittmann et al., Reference Wittmann, Schredl and Kramer2007). The content of PTSD- related nightmares varies from disturbing nightmares unrelated to the trauma to nightmares that are explicit replications of the traumatic event (Wittmann et al., Reference Wittmann, Schredl and Kramer2007). A recent meta-analysis of dream reports during REM and non-REM sleep showed that episodic memories (to which traumatic memories belong) are processed significantly more frequently by non-REM mentation than by REM mentation, with 75% of a night's sleep spent in the non-REM state (Baylor & Cavallero, Reference Baylor and Cavallero2001). Equivalent amounts of non-REM sleep deprivation are as deleterious to mental health as REM sleep deprivation, therefore both REM and non-REM sleep states are fundamental to the maintaining mental health (Nielsen & Levin, Reference Nielsen and Levin2007; Hobson, Reference Hobson2009).
There is a significant relationship between nightmare frequency and sleep disturbances including insomnia, sleep onset latency, awakenings, and restless or fitful sleep (Krakow et al., Reference Krakow, Tandberg and Scriggins1995; Hublin et al., Reference Hublin, Kaprio and Partinen1999). Successfully treated nightmare patients frequently report improvements in sleep quality, feeling more rested upon awakening, and having more daytime energy (Krakow et al., Reference Krakow, Tandberg and Scriggins1995). In these same studies a persistent pattern emerged of decreased psychiatric distress (depression, anxiety, or PTSD symptoms) following successful nightmare treatment (Krakow, Reference Krakow, Germain and Warner2001; Germain & Nielsen, Reference Germain and Nielsen2003). To treat sleep disturbances and the associated psychiatric distress, Krakow and his colleagues developed a therapy called “imagery rehearsal therapy” (IRT) (Krakow et al., Reference Krakow and Zadra2006), which combines two methods of treating nightmares: viewing nightmares from the perspective of a learned sleep disorder, and as a damaged imagery system.
The literature on sleep disturbance in cancer patients documents the substantial physiological changes that result from the disease process and from treatments (chemotherapy, surgery, radiation), and acknowledges that insomnia is more prevalent in cancer patients than among the general population (19–63% insomnia versus 9%) (Kvale & Shuster, Reference Kvale and Shuster2006). Among cancer patients, 52% attributed their sleep disturbance to “intrusive thoughts,” and 45% to physical discomforts (Davidson et al., Reference Davidson, MacLean and Brundage2002). Sleep disturbances become more predominant in the terminal phase of cancer, with 70% of patients reporting frequent awakenings (Mercadante et al., Reference Mercadante, Girelli and Casuccio2004). In spite of the fact that there is well-documented evidence of sleep disturbance in cancer patients, insomnia tends to be underreported by patients. In one study, only 16% of cancer patients reported their sleep disturbance to healthcare providers (Engstrom et al., Reference Engstrom, Strohl and Rose1999).
In short, the scientific literature on dreaming has documented the effects of external events upon quality of sleep in both REM and non-REM stages (Valli et al., Reference Valli, Revonsuo and Paikas2005). Sleep is essential to mental health, and sleep deprivation invariably causes psychological dysfunction (Hobson, Reference Hobson2009). Therefore, the integrity of waking consciousness depends upon the integrity of dream consciousness (Hobson, Reference Hobson2009). But most of the existing literature on insomnia in cancer patients to date has been concerned with physiological measures of sleep disturbance and its effects on the symptomatic status of the patient. Hence our paper will now discuss nine dreams collected from cancer patients, one from a family member, and two from oncology staff, in order to help cancer care clinicians understand and deal with dream content.
CLINICAL EXAMPLES
Patient Dreams
Fragments of dreams were related to one author (D.K.W.) during either office-based psychotherapy, hospital consultations in the oncology inpatient ward, or home visits with cancer patients. At the therapist's suggestion, patients spontaneously recalled these dreams and related their dream associations. Dreamer and therapist together developed the comments (interpretations). These six patient dreams are presented in a sequence, beginning with the least complex material and concluding with the most complex.
Dream 1/Patient 1
The patient was a 65-year-old married female with metastatic, terminal breast cancer. This dream occurred within 2 to 3 months of her death. She was homebound at the time of the dream. For the last year of her life psychotherapy was conducted weekly at her home, because she was too ill and debilitated to come to the office.
I was in a movie theatre on the ground floor. It was very dark. I heard my mother calling out to me from the balcony of the theater. It was so dark that I could not find her. I felt desperate and frantic to find her. I felt a lot of anxiety until I finally found her. It was such a relief to find her and reconnect with her.
Comment: For this patient the dream represented a vivid example of the wish for reunion with her mother and the relief felt in this context. The dream contains the element of preparation for death, being transported to a “higher” level (represented by the theater balcony), and her identification and merger with her mother, who had also died of breast cancer. The psychological experience of death-anxiety, so powerful as to make her regress to a childhood level of neediness (for her mother's presence), is also reflected in this dream. In life the patient was a particularly mature, self-contained, and resolute person who was the central maternal figure for her family. Hence the anxiety present in this dream was a notable departure from her usual conscious self. The dream element of her being in the dark represents her sense of dying and being without direction in that experience. This dream formed the basis for further exploration of her feelings, especially about dying, and subsequent resolution of many of her anxieties.
Dream 2/Patient 2
The patient was a 35-year-old Japanese-American married woman, with metastatic terminal breast cancer. These two dreams occurred close together during her chemotherapy. They were presented in office-based psychotherapy.
I was being put through a series of tests in which my life was at stake. The last one – the only one which I can remember – involved an Indian Guru. I was suspended from a wire and had to do a yoga-like contortion; if I made a wrong move, I'd fall to my death. I kept wondering if I'd make it. I was angry that things were so tentative, and that I had to keep proving myself. I made the right move and passed.
Comment: The patient believed that this dream reflected her sense of tension and tenuousness during chemotherapy. She had an excellent relationship with her medical oncologist, but she felt fearfully dependent on him and under his control at the same time. Her feeling about having to perform flawlessly for the guru/doctor appeared to be an extension of her childhood (and present-day) relationship with her parents. The sense of having to be a “perfect” daughter was central to their relationship, a daughter who performed flawlessly and presented no stress to them. She began to realize that she had repressed her anger at her parents, and that her dependence on the oncologist had reawakened some long dormant feelings. Understanding these feelings was an important theme in her psychotherapy and in coping with cancer treatment.
Dream 3/Patient 2
I dreamt an entire film one night. It began with me solving production problems – planning the shooting schedule. Then, the whole film unfolded: It was a documentary about a Japanese war bride. I directed the entire thing, asked the questions and was emotionally moved by the progression of the film. I dreamt the film cut by cut, and kept thinking how well it was going, that it was going to win an award.
Comment: The patient saw at once that this dream reflected many elements of her internal experience. First and foremost was her need to be in control and to direct her experience in the context of her metastatic cancer and chemotherapy, where she felt totally out of control and controlled by her oncologist. In her dream she reversed this and “directed” the entire experience. She also understood the importance of the Japanese war bride image. For her, this was the symbolic image of being a “stranger in a strange land.” The Japanese bride was dependent on a powerful male figure, and was transported to a foreign land where she did not speak the language. She began to understand that this image was a frank reflection of her existence in “cancer-land,” complete with dependency on a male oncologist who spoke “medical-ese.” It is important to appreciate the quality of dissociation in order to understand this dream. Rather than living the documentary story of the Japanese woman, she is separate from and watching it unfold “cut by cut.” She had undergone a mastectomy prior to her chemotherapy. The final element in the dream was the winning of an award. If her story was the most compelling to the oncologist, then he would reward her with complete and lifesaving attention. Her need to be the “best” patient and “best” daughter was a key theme in her psychotherapy, and these issues were explored in detail during the following sessions. She survived for eighteen months after the dream episodes.
Dream 4/Patient 3
The patient was a 67-year-old Caucasian single woman with breast cancer who had undergone a mastectomy. The dream occurred 3 months post-mastectomy. The dream was presented during an office visit.
I had a cat; I was cutting this cat in half – sawing it in half. I had pretty much cut it in half. There was a lot of blood. Why am I doing this? I took the cat, kind of squished it back together in one piece. I hadn't put the two pieces together right; it was limping. I was so guilt-ridden. What if it dies?
Comment: The patient was able to identify four key elements in her dream. First is a reversal of the experience of being cut. In the dream she has become the active cutter, not the passive recipient of the cutting. Second is her puzzling sense of guilt. Upon reflection, she began to understand that she had denied feelings of anger towards the surgeons for her mastectomy. She discovered she felt guilty and confused about being angry and “ungrateful” toward those who had saved her life. Third was her anticipatory anxiety of her upcoming breast reconstruction. She worried about it “not coming together,” hence “squishing the pieces together, I hadn't put two pieces together right.” As in the dreams of patients described above, her dream reverses reality with her being in charge of the reconstruction process. Finally, she confronted her basic underlying fear of death and all of the effort being for nothing (“What if it dies?”) Since childhood, she had struggled with not feeling entitled to care and still felt conflicted about being entitled to care despite her current medical situation. The bottom line was that she felt conflicted about being entitled to live at all, particularly given her feeling so ungrateful to her mother and then to her doctors. She is now alive and well 5 years post-mastectomy.
Dream 5/Patient 4
This patient was a 25-year-old male with B-cell lymphoma that recurred twice during the course of his illness. He underwent two bone marrow transplants, numerous courses of chemotherapy, and substantial radiation in his treatment process. This dream occurred a year after his initial course of chemotherapy. He was still recovering from chemotherapy that severely affected his appetite, created substantial weight loss, and required him to return to live at his parents' home while he recuperated. The dream was presented in office-based psychotherapy.
I was in Russia, in jail, on an island. There was an escape going on, should I sit there or run? Should I jump in the water and swim? There were other people there who said…mix in and you won't be noticed…a blond woman guard had a gun, they were all looking for me, I was trying to kill them. I don't know if I shot them or not.
Comment: The patient recognized several key elements of his current dilemma. Russia and jail reflected his feelings about having cancer and being forced to leave college and return to his parents' home. This felt bleak and deprived for him compared to the excitement and richness of life away at college. Next was the conflict to swim or not to swim. He admitted to wishing to blend in with other young adults like him and not to look special (like a cancer patient). This was countered by his concern that he could not swim with the others. This reflected a key element in his therapy, namely his acute self-consciousness about appearing weak, thin, emaciated, and emasculated by the chemotherapy. He wished to “blendin” but questioned his ability to cope on his own. Hence he had to remain “in jail,” at his parents' home, but under protest. He associated the blond female guard to his mother, a blond woman. In life she was caring but overbearing due to her anxiety about his condition and physical fragility. In the dream, she is the figure holding him prisoner. He associated himself with her and stated, “She is imprisoned by the disease along with me.” He acknowledged substantial guilt about the impact of his disease on her and the family. In the dream he hid and was elusive. In life, he distanced himself from his family despite living with them. He ate alone, and spent most of his time alone in his room. This one dream provided material for discussion during many of the following therapy sessions. He never fully recovered from his second exacerbation and died shortly after recounting the dream episode.
Dream 6/Patient 5
The patient was a 30-year-old male with acute mylogenous leukemia who was undergoing the process of bone marrow transplantation. This dream was presented in his hospital room on the Bone Marrow Transplant Unit (BMTU) during a routine visit for supportive psychotherapy. At the time of the dream, the patient was in the conditioning process, a period in which he was treated with massive doses of chemotherapy just prior to infusion of the bone marrow from his human leukocyte antigen (HLA) matched sibling-donor. As with all patients at this point in the process, he was weak, debilitated, and toxic from the combination of the full-body radiation and chemotherapy in the conditioning regimen.
I was having dinner in a busy Italian restaurant. I was seated in the dining room directly in front of the kitchen doors. The kitchen doors were the type that swing back and forth. They were constantly opening and closing, so I could see what was going on in the kitchen a lot of the time. Behind the swinging doors I saw a lot of chaos going on in the kitchen. The waiters and waitresses were bumping up against each other and seemed angry at each other for being in the way when they each were trying to get things done. I saw waiters and waitresses dropping plates on the floor. They dropped a lot of plates. I felt scared by what I saw, but especially scared when they dropped the plates.
Comment: This dream appeared to the patient and the therapist to be a complete reflection of his attempts to deal with his anxieties about the treatment milieu and procedures on the BMTU. The restaurant was a symbolic representation of the BMTU, which included the experience of being a passive onlooker at a staff that cares for and feeds its patrons. The patient identified three key elements in his dream. First was the visibility/transparency of the wait-staff in the restaurant. The staff of the BMTU, especially the nurses, was intensely present and their personalities, feelings, and conflicts became relatively well known to the patients. The patient–staff boundaries were more permeable and transparent than in most medical surgical units or services. Hence, the “swinging-door” revealed the foibles of the wait-staff. Next was the “angry waiters and waitresses bumping up against each other.” This appeared to be the patient's reaction to the dynamics of the BMTU physicians (mostly male) and nurses (mostly female), who frequently became irritable in their attempts to coordinate the care of these very ill patients who required such complex regimens of treatment. Such tensions often became obvious to the patients and families on the BMTU after a time. The final element was witnessing the dropped plates. It is essential to the survival of the patients on the BMTU that blood products, especially platelets, be properly maintained. Without proper platelet levels, patients are in acute danger of bleeding to death. They are frequently thrombocytopenic and require platelet transfusions. If the transfusions are done incorrectly, and the platelets are lysed (broken), the patient's survival is jeopardized. Therefore, the plate dropping in the dream represented anxiety over the competency of the BMTU staff's skill with platelet transfusion management. This was the point of maximal anxiety in the dream. These issues were subsequently explored, and the patient's anxiety level diminished markedly.
Dream 7/Family Member
The following is a dream of a mother whose 14-year-old son died of osteosarcoma ~6–8 months prior to the dream. This woman was in her mid-forties, a business executive, and was divorced from her deceased son's father. She had an older daughter, age 20. She had sought bereavement therapy after her son's death. The dream was presented in office-based psychotherapy.
I am walking through a forest… it is quite hazy and I cannot decide at first if it is fog or what, but I notice all the trees are bare and smoldering and realize that there has been a forest fire there, and the smoke is still present, and occasionally a red glow. I have my son with me, much younger than he was, and I am trying to get us through there. Suddenly I realize that my son isn't with me anymore. Looking up in the trees I find portions of his body hanging from them…a limb here, a torso there, but all recognizable to me as my son. Then it somehow changes, and I am going through the forest but the younger (version of my) son is with me and I am feeling that if I hurry and do everything just right then I will get him out of there safely.
Comment: This dream has several elements germane to her experience of her son's illness and death, and her own struggle to make sense of the experience and progress in her bereavement.
First is the sense of decimation. The fire may represent a metaphor for the decimation brought by the cancer. Not only has it taken her son, but it decimated her whole world as well. The entire world is scorched and barren. The haze and fog impart an eerie, dissociative quality of unreality to the experience. The occasional red glow appears to reflect the surges of red-hot pain and grief that she experiences, which push through the fog of numbness she frequently reported in her therapy. Her internal emotional experience oscillated between numbness and periods of debilitating, agonizing pain. Next is the younger son who is with her (twice in the dream). This appears to represent a wish to predate the cancer and somehow be smart enough to circumvent and think her way out of the cancer experience. She was a highly successful business executive who always tried to construct elaborate, highly detailed business plans. An overwhelming sense of responsibility is present in the dream within the notion… “If I hurry and do everything just right then I will get him out of there safely.” She was guilt-ridden and felt that she should have done things right, but failed and as a result, her son died. This represents an almost universal conflict for family members of cancer patients who have died. At a deeper level, this is a defense against the more disturbing reality that she was helpless to guide her son; all her thinking and planning had proved useless in fending off the forest fire of the cancer. Finally, the images of fragmentation:“a limb here, a torso there.” These contain elements of post-traumatic stress and the trauma of having witnessed her son's body coming apart due to cancer and cancer treatment. In addition, she felt fragmented herself, as often reported in therapy “in pieces, my life is in pieces.”
She responded very well to extensive psychotherapy using the themes revealed in the dream that helped her deal with these issues and gradually overcome the devastating loss that she experienced.
The remaining two dreams are from two different staff nurses on the BMTU. These dreams were presented in the context of a nurses' support group on the unit, facilitated by one author (D.K.W.) and by another faculty member of the Consultation-Liaison Psychiatry Service. The groups were held weekly on the BMTU.
Dream 8/Nurse 1
“I dreamed Dr. H (faculty attending oncologist) was telling me I had leukemia. He was giving me my diagnosis… I said, oh no, don't tell me that.”
Comment: A common conflict for the BMTU nurses was the inability to separate, even on days off from the unit. The group was able to identify the themes of the loss of boundaries, identification with the young adult patient population, and sense of vulnerability so frequently felt by this group of nurses. This dream represents the ultimate form of merger with the unit and patients: the nurse herself dreams of being diagnosed with leukemia.
Dream 9/Nurse 2
“I dreamed Paul McCartney finally noticed me…I have always loved him. As he was walking closer and closer toward me, I saw he had GVH [graft-versus-host disease] and scleroderma type skin.”
Comment: All of the nurses in the group recognized that this dream embodies a fundamental conflict experienced by the most of the BMTU nurses. They struggled with guilt over inducing severe symptoms, side-effects, and suffering via the conditioning treatment they administered to the patients leading up to bone marrow transplantation. They would begin to treat a patient with leukemia who had a disease but who was not acutely ill. By the time that the conditioning and the bone marrow transplant were done, the patient was profoundly ill and debilitated, most often including graft-versus-host disease. Therefore, anyone whom the nurses treated became acutely ill as a result of the treatment that the nurses administered. The image of Paul McCartney who, once he came close was no longer vibrant but profoundly ill, reflects this experience. Although the nurses were intellectually aware that they administered these treatments for good reasons, emotionally they came to feel conflicted, guilty, and responsible for inducing suffering in those very patients they cared about and with whom they had formed relationships over time. Discussion of the dreams in the context of supportive group meetings was found to be helpful in increasing nurses' morale, self-esteem, and sense of fulfillment as healthcare professionals. The therapists clarified the nurses' fears about of harming their patients instead of healing them in the context of having to administer such powerful conditioning treatments. Nurses on BMTUs give medications and supervise regimens that are more powerful and toxic than the drugs that nurses give patients with less life-threatening diagnoses on other hospital wards. When the nurses perceived themselves as helping patients cope with such taxing protocols, when they saw themselves as healers, their feelings of self-recrimination diminished and their morale improved considerably.
DISCUSSION
Our review of the literature reinforces the importance of dreaming as an active state of mind involved in threat assessment and threat rehearsal (Valli et al., Reference Valli, Revonsuo and Paikas2005). Cancer represents a prime example of threats to the patient, family, and healthcare professionals who care for these patients. Cancer is well known as a cause of “troubled sleep” (Davidson et al., Reference Davidson, MacLean and Brundage2002; Kvale & Shuster, Reference Kvale and Shuster2006) among cancer patients. It therefore merits careful consideration by oncology care professionals who can offer effective treatments once they understand more about their patients' dreams.
Healthcare professionals in various medical specialties recognize the connection between diseases and resultant insomnia (Davidson et al., Reference Davidson, MacLean and Brundage2002). Poor sleep creates feelings of fatigue, compromised ability to cope with stress, feeling more “down” than usual, and being unable to perform tasks and fulfill responsibilities. These findings lend additional support to Hobson's proposal that the “brain states” underlying both waking and dreaming cooperate, and that this cooperation is critical to optimal functioning in both waking and dreaming modes (Hobson, Reference Hobson2009). In this article, we sought to extend Hobson's concept to psycho-oncology so that the “story line” and feelings in each dream are as relevant as the neurobiology of dreams.
We suggest that oncology healthcare professionals invite their patients to discuss troubling and pleasant dreams with them. We expect that healthcare professionals will repeatedly hear certain themes including: (1) threat assessment and attempts to actively engage with a threat; (2) concerns about feeling dependent, passive, and full of dread; and (3) the relationship with oncology healthcare professionals. The most affect-laden and complex dreams in this article touch on the powerful relationships between patients and their oncologists (hanging from a tightrope, sawing the cat in half) reflecting the fearful experience of dependency, the unreasonable expectation of flawless performances by both patient and physician, and barely contained anger directed at the physician. These are some of the most difficult feelings to express and accept by patients and providers alike. Assisting the patient to become aware of and to tolerate this type of conflict is potentially one of the greatest values of doing dream work with cancer patients and their families.
Disturbing dreams are not usually discussed openly during appointments. Instead, they are “encrypted” into complaints about insomnia or “poor sleep.” Providers address such complaints with prescriptions for hypnotics, anxiolytics, and narcotics rather than any further exploration of possible causes for sleep disturbance beyond just physical symptoms (Kvale & Shuster, Reference Kvale and Shuster2006). Such exploration requires more time and often pushes the experiential boundaries of the healthcare professionals' competence. It requires interest, empathy, and tolerance for discomfort to hear patients relate dreams embodying dependence on the physician for everything from physical comfort measures to life and death. Dreams can range in content, from a patient's gratitude for being treated, to resentment for being disfigured (the breast cancer patient who underwent a mastectomy and subsequent reconstruction), and feelings of futility about treatment (“Why am I doing this…?).
The other dreamers include healthcare providers who feel deeply and must compartmentalize their own feelings. As is reflected by the dreams of nurses in this article, the staff's daily experiences and dreams can often mirror their patients' conflicts about treatment. If patients experience conflict about being treated, the staff's dreams reveal their own conflicts about giving (or inflicting) treatment. Staff members intellectually understand the benefits of giving often toxic treatments, but simultaneously feel guilty and responsible for inducing suffering as well.
We have addressed some reasons for disturbed sleep and disturbing dreams in cancer patients, family members, and caregivers, and we propose that inquiring about such dreams can assist the caregivers in offering psychological interventions as well as medications. One such intervention has been shown to alter disturbing dreams, also termed “nightmares.” In a comprehensive review of clinical interventions for chronic nightmares, Krakow and Zadra (Reference Krakow and Zadra2006) argue that IRT, which is a cognitive-imagery approach, is effective in revising the nightmare experience and thereby improving sleep quality. Nightmares are frequently associated with traumatic events, and appear as one of the symptoms of PTSD. Krakow and Zadra sought to change their patients' beliefs that bad dreams emerged from the unconscious and would therefore be uncontrollable. In fact, Krakow and Zadra (Reference Krakow and Zadra2006) taught their patients that nightmares are a learned behavior that can be “unlearned.” These researchers described nightmares as a re-experiencing (intrusion) of traumatic events. This creates a “cascade” of mental and physical hyper-arousal symptoms triggered by the threats contained within the disturbing dreams. Naturally, patients seek to avoid the “trigger,” which is falling asleep, in a maladaptive attempt to avoid more nightmares.
Krakow and Zadra (Reference Krakow and Zadra2006) went on to develop a model for intervening into and altering this sleep disturbance. We view this intervention as potentially applicable to the oncology experience. We agree with Krakow and Zadra that nightmares can be paradoxically beneficial, by providing useful information for emotional processing. In addition, reviewing nightmares can help the dreamer learn to avoid or reduce danger by modifying his or her behavior. This correlates with Valli et al.'s (Reference Valli, Revonsuo and Paikas2005) theory of threat assessment and rehearsal. After teaching patients that nightmares are learned behaviors, and therefore modifiable, Krakow and Zadra introduced the concept of “imagery.” This is a natural mental activity, often the last conscious activity prior to sleep. Imagery by day may be a bridge to imagery during sleep (dreams/nightmares). Imagery resembles daydreams with more built-in structure and intention. As such, an individual can practice changing mental images, replacing unpleasant ones with neutral or even pleasant images. This process of practicing imagery skills can result in empowerment, an increase in positive feelings, and an increased sense of relaxation (Nelson & Harvey, Reference Nelson and Harvey2003a, Reference Nelson and Harvey2003b; Menzies & Taylor, Reference Menzies and Gill Taylor2004).
To illustrate how IRT might be applied to the oncology setting, we consider dream 6 about the Italian restaurant where the staff is dropping plates in front of the patient. We might invite the patient to “change (the dream) in a way that feels right to you” (Krakow & Neidhardt, Reference Krakow and Neidhardt1992). It suffices to practice changing only one element in the dream. This might involve the patient imagining that he is addressing the wait- staff politely but firmly, reminding them to handle the plates (and platelets) more carefully, and to respect each other. The patient thus moves from being a terrified “customer” (patient) to being an empowered person and masterful partner in the medical process.
The central thrust of IRT is to educate and empower dreamers so that they do not have to be victimized by repetitive nightmares and the subsequent diminished quality of life that follows interrupted sleep. Including this modality offers cancer patients access to a non-pharmacological intervention that could improve both their waking and sleeping hours, and offers oncology healthcare providers a new tool to offer to their patients. Furthermore, if healthcare providers feel that this is a effective intervention, they may be more likely to inquire about their patients' bad dreams, knowing that they can offer support and intervention, resulting in the providers and the patients feeling less passive, less victimized, and less avoidant.
CONCLUSION
This article serves to review the extensive literature on dreams, the neurobiology of sleep, and the effect of cancer and its treatments on the quality of sleep. Several dreams are discussed and interpreted to illustrate the impact of the interaction between cancer, cancer treatment, and disturbed sleep. Furthermore, these dreams reveal the powerful interdependence of patients and healthcare providers and the hidden conflicts that often arise between them during the course of treatment. We offer a perspective on non-pharmacological treatments in the context of current sleep theories and interventions to relieve cancer patients' feelings of threat and trauma, which are often manifested in nightmares. We hope that this will empower healthcare providers to make good use of their patients' disturbing dreams.
ACKNOWLEDGMENTS
We thank Christina Rothans, Staff Research Assistant at the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA for her help and ideas in preparing this manuscript.
