Dream processes and affect regulation in psychotherapy: a longitudinal clinical case study

Abstract

Anxiety disorders frequently emerge in contexts of chronic interpersonal stress and are often accompanied by disturbances in affect regulation and heightened sensitivity to bodily signals. In patients with chronic somatic conditions, these processes are commonly conceptualised within psychosomatic frameworks emphasising interactions between emotional regulation and stress-related bodily systems. Although psychotherapy may facilitate psychological adaptation, less is known about how dream processes reflect ongoing changes in affect regulation during treatment. The present study explores longitudinal changes in dream narratives during psychotherapy in a patient with anxiety and depressive symptoms in the context of ulcerative colitis. A qualitative, process-oriented longitudinal case study was conducted within analytically oriented psychotherapy with a 28-year-old patient. Over one year, the patient recorded dreams, from which five clinically significant dreams were selected. Dream reports were analysed alongside psychotherapy process notes and in-session associations using thematic analysis, informed by Jungian amplification. Three thematic constellations were identified: vulnerability and loss of control; threat perception and emotional overwhelm; and emerging control and agency. Early dreams reflected helplessness and heightened threat sensitivity, whereas later dreams increasingly depicted the dream-ego as capable of recognising danger and responding more adaptively. Findings suggest that dream processes may serve as indicators of changes in affect regulation and relational functioning, offering a process-sensitive window into psychotherapeutic change in psychosomatic contexts.

Introduction

Anxiety and depressive disorders are among the most prevalent psychiatric conditions worldwide and represent a major source of disability and reduced quality of life (Kessler et al., 2005; Whiteford et al., 2013). These disorders frequently co-occur with chronic medical illnesses, where ongoing physical vulnerability, illness uncertainty, and persistent bodily symptoms may contribute to heightened psychological distress. In such contexts, patients often develop increased vigilance toward bodily sensations and difficulties in regulating stress and affective states, which may further exacerbate emotional suffering (Bandelow & Michaelis, 2015). Inflammatory bowel disease, including ulcerative colitis and Crohn’s disease, represents one example of a chronic condition in which elevated rates of anxiety and depressive symptoms have been repeatedly documented (GBD 2017 Inflammatory Bowel Disease Collaborators, 2020; Neuendorf et al., 2016). Clinical observations suggest that psychological distress in these patients often emerges within a complex interaction between emotional regulation difficulties, interpersonal stress, and heightened sensitivity to bodily states.

Within contemporary psychosomatic perspectives, chronic medical conditions are increasingly understood as dynamic interactions among physiological vulnerability, emotional processes, and environmental stressors (Bonaz & Bernstein, 2013; Gracie et al., 2018). In this framework, bodily symptoms and psychological states are closely interconnected through stress-regulatory systems involving neuroendocrine, autonomic, and affective processes. Patients living with chronic illness often report heightened sensitivity to stress and a persistent sense of reduced bodily control, particularly during periods of interpersonal conflict or emotional uncertainty. These experiences may contribute to increased vulnerability to anxiety and depressive symptoms.

Psychotherapeutic interventions in such contexts frequently focus on strengthening emotional regulation capacities and helping patients develop a more coherent understanding of the relationship between stress, relational experiences, and bodily signals. Adapting to chronic illness often requires an ongoing process of integrating bodily vulnerability into one’s sense of self while developing new strategies of self-regulation and coping (Ambrosio et al., 2015). Importantly, these regulatory processes unfold within broader interpersonal and social contexts that shape how individuals manage the psychological challenges of long-term illness (Vassilev et al., 2014).

One potential window into these regulatory processes may be found in dreaming. From a neuroscientific perspective, dreaming can be understood as a distinctive brain state in which internally generated experiences unfold largely independent of external sensory input. During rapid eye movement (REM) sleep, the brain remains highly active and capable of constructing complex experiential worlds, supporting the view that dreaming may function as an endogenous simulation space for emotionally salient experiences. Neuroimaging studies have demonstrated increased activation of limbic and paralimbic regions during REM sleep – including the amygdala, anterior cingulate cortex, and medial temporal structures – alongside reduced dorsolateral prefrontal control (Dang-Vu et al., 2010; Nir & Tononi, 2010). This neurophysiological configuration may create favourable conditions for the reactivation and integration of emotionally charged memory traces.

Within contemporary affective neuroscience, dreaming is therefore increasingly conceptualised as part of broader systems involved in emotional processing and memory reconsolidation. Sleep, and REM sleep in particular, may facilitate the reactivation and updating of emotionally significant experiences across repeated sleep-wake cycles (Lane et al., 2015). From this perspective, dream narratives may reflect ongoing processes of emotional integration and affect regulation occurring outside of conscious awareness.

In the present study, affect regulation refers to the capacity to modulate emotional experiences and responses in ways that support adaptive psychological and interpersonal functioning (Gross, 2015). Within this framework, changes in dream-ego functioning are interpreted as symbolic expressions of evolving affect-regulatory capacities during psychotherapy rather than as direct measures of emotion regulation.

Clinical observations have long suggested that the dream-ego – the representation of the dreamer’s conscious standpoint within the dream (Jung, 1964) may provide insight into psychological functioning beyond the manifest dream content. Within Jungian dream theory, the behaviour of the dream-ego is considered clinically informative because it reflects how the dreamer perceives, responds to, and engages with emotionally significant situations within the dream world (Jung, 1964; Roesler, 2018). Longitudinal changes in dream-ego functioning have therefore been proposed as one indicator of psychotherapeutic change, with dream-ego behaviour often shifting from passive or immobilised responses toward more agentic forms of engagement as treatment progresses (Ableidinger et al., 2025).

The present study examines a longitudinal series of dreams emerging during analytically oriented psychotherapy with a young woman presenting with an anxiety disorder and a depressive episode in the context of a chronic medical condition (ulcerative colitis). Particular attention is given to how the behaviour of the dream-ego evolves across the therapeutic process and how these changes may reflect emerging patterns of affect regulation and psychological organisation. To the best of our knowledge, no published longitudinal clinical case study has specifically examined changes in dream-ego functioning as an indicator of affect regulation throughout psychotherapy in a patient with a chronic somatic illness, highlighting an important gap that the present study seeks to address. Rather than attempting to draw mechanistic conclusions from a single case, the present analysis investigates the potential role of dream processes as indicators of changes in affect regulation and relational functioning, offering a phenomenological window into the evolving integration of emotional experience, relational dynamics, and bodily vulnerability during psychotherapy.

Materials and Methods

The study follows a process-oriented clinical case study design focusing on within-case change over time, with particular attention to affect regulation and relational processes.

Ethical considerations

Ethical considerations were carefully observed throughout both the therapeutic process and the preparation of the present case study. The patient provided written informed consent for the use of anonymised clinical and dream material for research and publication purposes. Consent was obtained during a later and more stable phase of the therapeutic process, after the aims of the study and the nature of the publication had been explained in detail. It was emphasised that participation was entirely voluntary and that the decision to participate would have no influence on the therapeutic relationship or the continuation of treatment.

Because the first author was also the treating therapist, particular care was taken to ensure that the consent process respected the patient’s autonomy and avoided any potential pressure related to the therapeutic relationship. All potentially identifying personal information has been modified or removed to protect the patient’s anonymity while preserving the clinical integrity of the case material. Dream reports are presented in their original form in order to maintain their phenomenological richness and clinical relevance.

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and with professional guidelines concerning the publication of clinical case material. Given the single-case, non-interventional nature of the study and the full anonymisation of the material, no additional risk to the patient was identified. The patient provided written informed consent for publication of anonymised clinical material. According to national regulations, formal ethical approval was not required for single-case studies using fully anonymised data.

Case description

The patient, referred to here as Louisa (pseudonym), is a 28-year-old general practitioner resident living with ulcerative colitis. She entered weekly individual psychotherapy within a Jungian analytic framework conducted by a Jungian psychoanalyst. The therapeutic work focused on relational patterns, dependency dynamics, and the symbolic exploration of inner experience, including the discussion of dreams.

At the time of entering therapy, Louisa was involved in a longterm but unstable romantic relationship characterised by repeated cycles of separation and reconciliation. She reported that periods of heightened relational stress were frequently accompanied by exacerbations of gastrointestinal symptoms. The emotional distress associated with both relational instability and physical symptoms played an important role in her decision to seek psychotherapy.

At the beginning of treatment, Louisa presented with elevated anxiety, pronounced self-doubt, and a sense of being “stuck” in her relational life. During the early phase of therapy she met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) diagnostic criteria for generalised anxiety disorder and presented with clinically significant depressive symptoms associated with ongoing relational stress (American Psychiatric Association, 2022). Due to the severity of depressive symptoms, she was referred for psychiatric evaluation. The diagnosis was subsequently confirmed by a consulting psychiatrist, and she remained under psychiatric follow-up during part of the therapeutic process. During the first half of psychotherapy, she experienced difficulties initiating sleep but did not receive psychotropic medication. In the second half of treatment, following psychiatric evaluation, she started treatment with escitalopram (10 mg/day), which remained stable throughout the remainder of psychotherapy. Neither the patient nor the therapist observed clinically noticeable changes in dream frequency, vividness, or recall following the initiation of pharmacotherapy; however, the potential influence of medication on dream material cannot be entirely excluded. Psychotherapy therefore proceeded alongside psychiatric care.

Despite these psychological difficulties, Louisa was able to maintain her professional functioning and continued to work as a general practitioner resident during this period. She had no previous psychotherapeutic treatment before entering the present therapy. She is of European background and was living and working in an urban environment at the time of treatment.

Dream collection procedure

At the initial psychotherapy session, the patient was informed that dream work constitutes a routine component of Jungian-oriented psychotherapy and was invited to record any dreams she could recall throughout treatment. She was asked to write down each remembered dream as soon as possible after awakening, using the notes application on her mobile phone.

Dream recording served exclusively therapeutic purposes and was not initiated as part of a research project. The patient sent each written dream report to the therapist before the following psychotherapy session, allowing the therapist to review the material in advance. Dreams were subsequently discussed together with the patient’s spontaneous associations whenever clinically appropriate. Although not every recorded dream could be explored in equal depth because of therapeutic priorities and time constraints, all dreams included in the present study were discussed extensively during psychotherapy. The decision to prepare this case study emerged retrospectively after the first year of treatment, and the patient subsequently provided separate written informed consent for the anonymised scientific use of her clinical material.

Dream selection

Throughout the therapeutic process, the patient reported dreams frequently, often several times per week. Many of these dreams were only briefly mentioned during sessions, while others were explored in greater depth within the analytic process. Dream recording remained consistent throughout the approximately one-year psychotherapy process. Based on clinical observation, no substantial changes were noted in the patient’s motivation to record dreams or in her subjective ability to recall dreams over time. The present study focuses on those dreams that became central elements of the therapeutic dialogue and were examined together with the patient’s associations and the surrounding clinical context.

Dream material was analysed in conjunction with psychotherapy process notes and significant life events occurring during treatment. Particular attention was given to dreams emerging during emotionally salient periods, including relational crises, important therapeutic insights, and phases of heightened psychological distress.

Psychotherapeutic change rarely follows a strictly linear trajectory and often involves oscillations between periods of regression and progress (Hayes et al., 2007; Hayes & Andrews, 2020; Schiepek, 2009). Accordingly, the analysis did not assume a steady increase in dream-ego agency over time. Instead, the focus was placed on patterns in which moments of increased agency emerged during emotionally significant phases of therapy. For this reason, the dream vignettes are not presented in strict chronological order but are organised thematically to highlight clinically meaningful developments observed across the therapeutic process.

During psychotherapy, Louisa recorded more than 150 dreams. The scope of the present study did not allow for the presentation of the full dream corpus. Therefore, reflexive thematic analysis (Braun & Clarke, 2006, 2019) was conducted across the entire set of recorded dreams to identify recurring experiential and symbolic patterns. The thematic analysis was based on the complete dream corpus rather than solely on the five dreams presented in this manuscript. Following identification of the thematic structure, five dream vignettes were selected because they most clearly illustrated the identified thematic constellations and had also been explored in depth during psychotherapy sessions. Given the scope of a singlecase report, only these five information-rich dream vignettes were included in the manuscript. Together, they illustrate the broader thematic patterns identified across the complete dream corpus while representing different configurations of dream-ego functioning across different phases of psychotherapy. This approach enhanced the transparency and credibility of the analytic process by grounding the presentation of the selected dream vignettes in the thematic structure of the complete dataset.

Analytic layers and sources of clinical material

Dream material was analysed in conjunction with psychotherapy process notes and the patient’s in-session associations. The analytic material therefore consisted of four complementary sources:

1. the patient’s written dream reports;

2. psychotherapy process notes documenting the therapeutic context;

3. the patient’s verbal associations expressed during sessions;

4. retrospective clinical interpretation developed during the preparation of the present study.

In the presentation of results, dream extracts are followed by brief descriptions of the therapeutic context in which the dream occurred, including relevant life events and relational developments discussed in therapy. These contextual descriptions are accompanied by clinical reflections focusing on the dream-ego’s capacity for agency, emotional regulation, and relational positioning.

In addition to clinical interpretation, the analysis was guided by principles of thematic analysis (Braun & Clarke, 2006, 2019), which supported the identification of recurring experiential and symbolic patterns across the dream narratives.

Analytic approach to dream interpretation

Dream interpretation was further informed by principles of analytic dream work within the Jungian tradition (Jung, 1964). In this framework, dream images are explored through the patient’s personal associations and through symbolic amplification.

Amplification is a Jungian interpretative method that explores dream motifs through symbolic parallels drawn from mythology, religion, cultural traditions, and other collective motifs while remaining grounded in the dreamer’s personal associations. This process situates individual dream material within a broader symbolic and psychological context through symbolic amplification while remaining grounded in the dreamer’s personal associations (Jung, 1964; Samuels et al., 1986).

Rather than imposing fixed symbolic interpretations, amplification functions as a heuristic tool that situates dream material within broader patterns of meaning while remaining grounded in the patient’s experiential associations. This interpretative approach supported the exploration of recurring dream motifs related to threat, vulnerability, care, and autonomy within the therapeutic process.

Analytic procedure

The analytic process followed a two-step procedure combining reflexive thematic analysis with clinically informed interpretative analysis. First, reflexive thematic analysis was applied to the dream corpus to identify recurring experiential patterns. Second, these themes were interpreted within a Jungian analytic framework using the patient’s associations and clinical context. This two-step approach allowed for a systematic identification of patterns while retaining sensitivity to clinically meaningful interpretation.

Researcher position

The first author, a 30-year-old female clinical health psychologist undergoing advanced training in Jungian psychotherapy, also served as the treating therapist throughout the psychotherapy process. The interpretations presented here therefore emerged both from the therapeutic process and from retrospective analytic reflection during the preparation of the manuscript. Throughout psychotherapy, the case was discussed in weekly individual clinical supervision with an experienced Jungian training analyst. These supervision sessions focused on the therapeutic process, including transference-countertransference dynamics and clinical decision-making. During the preparation of the manuscript, the second author, who is also an experienced psychotherapist, independently reviewed the development of the themes and the interpretation of the clinical material, providing critical feedback throughout the analytic process. Efforts were made to ground interpretations primarily in the patient’s own associations and the documented therapeutic context. At the same time, it is acknowledged that the analysis inevitably reflects a clinical perspective shaped by Jungian psychotherapy. The combination of regular clinical supervision and independent review of the analytic interpretations supported reflexive consideration of the first author’s dual role as therapist and researcher and enhanced the credibility of the findings.

Transference and countertransference dynamics

The therapeutic process was characterised by intense transference-countertransference dynamics, closely related to the patient’s relational history and underlying complex constellations (Jung, 1960).

In the transference, the patient’s relationship to her romantic partner appeared to reactivate earlier paternal dynamics, particularly experiences of emotional unpredictability, ambivalence, and dependency. These patterns gradually extended into the therapeutic relationship, where the patient at times exhibited strong dependen-

cy needs, especially during periods of crisis or emotional destabilisation. In such moments, she expressed a pronounced fear of abandonment and sought proximity and reassurance from the therapist, suggesting the activation of both paternal and maternal transferential configurations.

From the perspective of the therapist, the countertransference was marked by a strong sense of responsibility to provide a stable and containing presence, accompanied at times by emotional strain. The patient’s recurrent suffering and her continued involvement in a highly distressing relationship evoked an ongoing tension between maintaining a containing therapeutic stance and supporting the patient’s emerging autonomy.

This dynamic at times led to experiences of therapeutic impasse. It became particularly evident in situations where the patient had difficulty integrating ambivalent representations of her partner, especially in allowing awareness of his negative or harmful aspects. In such moments, increased resistance emerged, occasionally manifesting in disruptions of therapeutic continuity (e.g., missed sessions).

In addition, elements of projective identification appeared to be present, as the patient’s unexpressed anger toward her partner was at times experienced within the therapist as affect that needed to be held and processed in the analytic space. This contributed to a complex emotional field in which the therapist had to manage both empathic attunement and internal tension.

Maternal transferential dynamics were also evident. The patient’s dependency needs and fear of abandonment evoked in the therapist a pressure to assume a “good-enough” maternal function, while simultaneously maintaining the analytic stance and supporting the patient’s autonomy. This created an ongoing balancing process between providing emotional containment and avoiding over-involvement.

These dynamics can be understood within a Jungian framework as expressions of activated relational complexes, referring to emotionally charged patterns of perception, affect, and behaviour organised around early relational experiences (Jung, 1960; Knox, 2003). Within this framework, paternal and maternal imagos shaped both the patient’s relational expectations and the intersubjective field of the therapeutic relationship.

Results

The results are presented in three parts: i) clinical background, ii) course of psychotherapy, and iii) thematic analysis of dream material.

Clinical background of the case

Louisa entered psychotherapy during a period of significant emotional distress associated with an unstable romantic relationship. At the time, she was involved with a partner who was considerably older and whose attitude toward the future of the relationship remained uncertain. Periods of intense emotional closeness were frequently followed by withdrawal, ambivalence, and conflict, creating a persistent sense of insecurity that Louisa experienced as emotionally exhausting. She described feeling strongly attached to the partner and reported considerable difficulty distancing herself from the relationship despite recognising its destabilising effects. As she later reflected, “I couldn’t imagine my life with anyone else, despite all the warning signs. I felt completely trapped in the relationship, as if losing him would mean the end of everything”. Moments of relational tension were often accompanied by feelings of helplessness, heightened anxiety, and emotional overwhelm. She also perceived a clear connection between relational stress and fluctuations in her physical condition, noting that periods of conflict were frequently followed by exacerbations of her ulcerative colitis symptoms, including increased bowel urgency and gastrointestinal discomfort. Louisa entered psychotherapy with the intention of better understanding these dynamics, strengthening her ability to maintain personal boundaries within the relationship, and regaining a sense of control both in her relational life and in relation to her bodily functioning.

Louisa reported that the emergence of persistent anxiety symptoms coincided with the beginning of the unstable romantic relationship. During this period, she developed increasing worry, hypervigilance, and a pervasive sense of lacking control within the relationship. The anxiety gradually intensified and was accompanied by growing social withdrawal and heightened sensitivity in interpersonal situations. When leaving home or entering social environments she often experienced the distressing feeling of being observed or judged by others. These experiences were accompanied by pronounced somatic anxiety symptoms, including sensations of throat constriction, shortness of breath, and episodes of intense internal tension. The anxiety was also accompanied by clinically significant sleep disturbance, particularly severe insomnia characterised by prolonged sleep-onset latency. For several months she reported sleeping no more than approximately 4 hours per night. Importantly, no anxiety disorder had been documented in her earlier medical or psychological history, and she associated the onset of these symptoms with the destabilising dynamics of the relationship.

In parallel with the escalation of these anxiety symptoms, gastrointestinal complaints became increasingly frequent and eventually led to the diagnosis of ulcerative colitis. Although she recalled having occasional digestive sensitivity earlier in life, more severe gastrointestinal symptoms emerged during this period of heightened emotional stress. The anxiety gradually generalised into persistent worry about her health, the stability of the relationship, and her ability to maintain control over her bodily functioning. She also experienced a depressive episode associated with relational distress. At the most difficult moments following the separation, Louisa reported experiencing transient thoughts that life might feel meaningless without the relationship, although she denied active suicidal intent and these thoughts subsided as therapy progressed. While depressive symptoms remitted over time, generalized anxiety remained a more persistent difficulty.

As the therapeutic process unfolded over the first year of treatment, it became increasingly apparent that Louisa’s relational expectations were strongly influenced by earlier experiences within the paternal relationship. She described her father as an emotionally intense and at times unpredictable figure whose behaviour could be experienced as intrusive and critical. According to Louisa’s report, her father had previously received a diagnosis of paranoid personality disorder according to DSM-5-TR criteria (American Psychiatric Association, 2022). The relationship was characterised by repeated cycles of closeness and rupture, often accompanied by feelings of fear, guilt, and emotional injury. Reflecting on this relationship, Louisa remarked: “For a long time he was my best friend. I idealised him. But as I grew into a woman something seemed to break – almost as if a veil had fallen. Since then, it feels as if I have been struggling with him inside myself”. Despite recognising the difficulties in this relationship, the emotional bond remained powerful.

These earlier relational experiences appeared to shape Louisa’s expectations within intimate partnerships. She reported that her connection with the partner felt immediately familiar, evoking emotional reactions reminiscent of those she had experienced in relation to her father. Over the course of therapy, patterns of dependency, fear of abandonment, and efforts to maintain relational closeness despite emotional cost became increasingly visible.

Despite these relational struggles, Louisa’s overall psychosocial functioning remained stable. Professionally she functioned at a high level, having completed medical training and maintaining an active professional and social life. Her difficulties therefore appeared relatively circumscribed to the domain of intimate relationships rather than reflecting a more global impairment in functioning.

Within this context, dream material provided a valuable perspective on the emotional and bodily processes unfolding during psychotherapy. The dreams appeared to capture shifts in how Louisa experienced vulnerability, threat, and control within both relational and bodily domains.

Course of psychotherapy

The first year of the psychotherapeutic process was characterised by distinct phases reflecting changes in the patient’s emotional functioning, relational patterns, and capacity for self-regulation.

In the early phase of therapy, the patient presented with high levels of anxiety, marked emotional dependency, and a pervasive sense of lack of control, particularly in relation to her romantic relationship. This period was characterised by intense affect, rumination, and difficulties in establishing psychological distance from a partner experienced as both desired and destabilising. Sleep disturbances and somatic symptoms were also pronounced during this phase.

In the middle phase of therapy, increasing insight emerged regarding the relational dynamics underlying her distress. In particular, connections between her current relationship and earlier experiences with her father became more explicit. This phase was characterised by oscillation between moments of greater clarity and episodes of emotional regression, reflecting the non-linear nature of the therapeutic process. The patient gradually began to recognise patterns of dependency, ambivalence, and fear of abandonment, although these remained affectively charged and difficult to regulate.

In the later phase of this first year, a shift toward greater autonomy and differentiation became observable. The patient demonstrated an increased capacity to reflect on her relational needs, tolerate ambivalence, and establish psychological boundaries. As part of this process, the romantic relationship was brought to an end, which, although experienced as emotionally challenging, represented a self-protective reorganisation rather than a collapse. The psychotherapeutic process itself, however, did not conclude during this period and continued beyond the timeframe described here. Alongside these changes, a reduction in depressive symptoms was observed, while anxiety remained present but became more manageable.

Across these phases, changes in dream narratives appeared to parallel the patient’s evolving capacity for affect regulation and relational self-organisation, providing a process-sensitive reflection of therapeutic change.

Organisation of dream material

Although the present study is based on longitudinal psychotherapy material, the dream vignettes are organised thematical-ly rather than chronologically. Psychotherapeutic processes rarely unfold in a simple linear manner; instead, motifs and experiential patterns tend to recur across different phases of treatment. The dreams presented here therefore illustrate shifting configurations of dream-ego functioning rather than a straightforward developmental progression.

Table 1 provides an overview of the dream vignettes and the corresponding configurations of dream-ego functioning identified in the case material.

Thematic analysis of dream material

Reflexive thematic analysis of the dream narratives identified three recurring thematic constellations reflecting different configurations of bodily experience, threat perception, and emerging agency within the dream material. These themes are summarised in Table 2.

The three thematic constellations include:

1. vulnerability, shame, and loss of control;

2. threat perception and emotional overwhelm;

3. emerging control and agency.

The following sections present selected dream vignettes organised around these thematic patterns. Each vignette is accompanied by the relevant clinical context and interpretative commentary focusing on dream-ego functioning and processes of affect regulation within the therapeutic context.

Dream 1 – The puppy and the snake

Dream vignette

I go to see a puppy that I would like to buy. The house is dirty and filled with different animals. When the woman finally puts a small animal into my hands, it is covered in feces and soils my sweater. I begin to worry that the animals are not properly cared for.

Each time I ask for the puppy, the woman gives me another animal instead. One after another different creatures are placed in my hands, none of them the puppy I came for. At one point I even consider taking a rabbit instead, although I know it is not what I originally wanted. In the room there are aquariums with reptiles and spiders. I notice a large snake very close to me and feel intense fear and disgust. The aquarium seems slightly open and I am afraid the snake might escape and harm the animals. I reach out and close the lid of the aquarium, which makes me feel somewhat calmer.

Later outside I see a large rat running in the grass. At first I feel strong disgust and fear, but eventually I realise it is not attacking us and I slowly calm down.

Clinical context

The dream occurred during a period in which Louisa was experiencing considerable emotional ambivalence in her intimate relationship with her partner. She described increasing anxiety and uncertainty regarding her ability to make autonomous decisions about the future of the relationship. This period was characterized by heightened emotional tension, persistent rumination, and a growing sense that she was losing contact with her own wishes and preferences within the relationship.

Table 1.

Dream motifs and configurations of dream-ego functioning across the therapeutic process.

Dream	Therapy phase	Central imagery	Dream-ego state	Affective theme
Puppy	Month 3 (early phase)	Contaminated animal, chaotic environment	Contamination, helplessness	Disgust, vulnerability
Stool	Month 5 (early phase)	Bodily exposure, stool on mattress	Shame, loss of control	Shame, exposure
Well	Month 7 (middle phase)	Deep layered well with threatening symbols	Encounter with unconscious threat	Anxiety, emotional overwhelm
Horse	Month 8 (middle/late phase)	Powerful but difficult-to-control horse	Emerging but unstable agency	Struggle for control
Ocean woman	Month 11 (late phase)	Guiding female figure, ocean descent	Expanded agency and emerging regulation	Integration, emerging self-regulation

Table 2.

Thematic structure of dream motifs and illustrative dream vignettes.

Theme	Illustrative dream vignettes	Core motifs	Clinical significance
Theme 1 – Bodily vulnerability and contamination	Puppy-snake dream; stool dream with John; nursing home scene (beginning of the ocean-woman dream)	Contamination; bodily shame; loss of control	Reflects experiences of vulnerability, shame, and exposure associated with heightened anxiety and difficulties in affect regulation
Theme 2 – Bodily threat and injury	Well dream	Bodily injury; pain; recognition of danger	Represents heightened threat perception and anxiety-driven vigilance in situations experienced as emotionally overwhelming
Theme 3 – Striving for control and agency	Horse dream; ocean-woman dream	Flight; regaining control; competence	Illustrates emerging dream-ego agency and developing self-regulatory capacities within the therapeutic process

The dream vignettes are illustrative examples selected from a longitudinal corpus of more than 150 recorded dreams. They were chosen because they most clearly represented the thematic patterns identified through reflexive thematic analysis and do not indicate the frequency with which each theme occurred within the complete dream corpus.

Patient associations

During the session, Louisa reflected that in the dream she clearly knew what she wanted – a puppy – yet somehow this desire repeatedly failed to materialise. Instead of receiving the animal she had chosen, she was repeatedly given something else. As she put it, “It felt as if I wasn’t allowed to choose what I really wanted”.

She associated the feces-covered puppy with a vulnerable and “repulsive” part of herself, describing it as a sick and dependent self-state that she found difficult to accept. She remarked, “It was as if I was holding the part of myself that I find the hardest to love”. She noted that the dream was dominated by feelings of disgust and discomfort, and that the environment felt chaotic and unsafe. Louisa also emphasised the frustration of being unable to make a free choice, as the situation seemed to prevent her from obtaining what she genuinely desired. She commented, “Everyone kept deciding for me, and I couldn’t get what I had come for”.

Psychodynamic interpretation

From a psychodynamic perspective, the dream appears to revolve around themes of vulnerability, shame, and conflicted self-experience. The contaminated animal may symbolically represent a disowned or devalued self-state associated with dependency and emotional exposure. Louisa’s intense feelings of disgust can be understood as indicating difficulty tolerating vulnerable aspects of herself that are experienced as unacceptable within the relational context.

The repeated substitution of animals instead of the desired puppy introduces a motif of frustrated desire and compromised autonomy. Although the dream-ego knows what it wants, this intention repeatedly fails to materialise. Such imagery may express Louisa’s waking experience of diminished agency within the relationship, where her own wishes often felt overshadowed by relational uncertainty and emotional pressure.

The dream environment itself appears chaotic, intrusive, and difficult to navigate, mirroring the patient’s experience of heightened anxiety and internal tension during this period of relational ambivalence. Within this context, the dream imagery suggests an internal landscape marked by conflicting impulses, emotional vulnerability, and uncertainty about how to assert personal needs within an unstable relational situation.

Dream-ego functioning

In this dream, the dream-ego appears initially overwhelmed by a chaotic and threatening environment, responding with anxiety and disgust. Despite this vulnerability, the dream-ego performs a small but meaningful regulatory action by closing the aquarium containing the snake, suggesting an emerging capacity to establish boundaries and restore a sense of control.

Dream 2 – The room and the stool

Dream vignette

I am staying at my grandparents’ house where a family event is taking place. My former partner, John, is also there, staying in a room downstairs. I know that my parents strongly disapprove of our relationship and try to keep distance between us.

I go into his room while he is not there and notice his clothes. I smell his sweater and feel how much I still care about him, even though I no longer trust him. Suddenly I urgently need to use the toilet. Afterward I realise that a piece of stool has accidentally fallen onto the mattress in the room. I feel intense shame and try to hide it.

At that moment John enters the room and approaches me with affection, while I try to keep my distance and avoid being seen together.

Clinical context

This dream occurred shortly after the definitive separation from Louisa’s partner. The relationship had been characterised by repeated cycles of emotional closeness and rupture, which she experienced as highly stressful and emotionally destabilising. In the period preceding the breakup, she had increasingly recognised that the relationship undermined her psychological well-being.

Following the separation, John had difficulty accepting the breakup and repeatedly attempted to re-establish contact. Louisa reported that he appeared at her home unannounced and continued to send messages, which she experienced as intrusive and anxiety-provoking. These encounters made it difficult for her to maintain emotional distance and complicated her efforts to establish clear relational boundaries.

Reflecting on this dynamic in therapy, Louisa described the emotional confusion of the relationship in the following way: “It is difficult when we expect comfort from the person who actually hurts us – when there is no real safety because the roles can change at any moment, and the one who comforts and the one who hurts are the same person”.

At the time of the dream, Louisa was attempting to maintain separation from her former partner while simultaneously struggling with persistent attachment and emotional ambivalence.

Patient associations

In session, Louisa immediately connected the dream to the recent breakup. She noted that in the dream her parents seemed to act protectively, attempting to keep distance between her and John, which she associated with the feeling that others could more clearly recognise the harmful aspects of the relationship.

At the same time, she emphasised that she still felt drawn to him, symbolised by the moment of smelling his sweater. As she reflected, “Part of me still wanted to be close to him, even though I knew I couldn’t trust him anymore”. She described this gesture as reflecting the lingering emotional bond she had not yet fully resolved.

Louisa also associated the appearance of stool in the dream with situations in which she experienced intense anxiety and a sense of losing emotional control during periods of relational tension. She remarked that “it felt deeply humiliating, as if all my vulnerability had suddenly become visible”.

Psychodynamic interpretation

From a psychodynamic perspective, the dream reflects a conflict between persistent attachment needs and emerging efforts toward psychological separation following the breakup. Although Louisa had consciously decided to end the relationship, emotionally significant bonds remained active, creating a state of ambivalence and internal tension.

The appearance of stool introduces a powerful theme of shame and exposure. Rather than primarily representing bodily vulnerability, this imagery may symbolise the patient’s fear of emotional exposure within an intimate relationship that had become psychologically unsafe. The experience of shame in the dream may therefore reflect the patient’s concern that her emotional needs or vulnerabilities could be judged, rejected, or used against her.

Within this context, the dream imagery suggests an internal conflict between longing for closeness and recognising the psychological cost of maintaining the relationship. The coexistence of attraction, mistrust, and shame reflects the patient’s broader struggle to regulate intense affect while attempting to establish clearer relational boundaries after the separation.

Dream-ego functioning

In this dream the dream-ego is caught between opposing movements of attachment and avoidance. While approaching the former partner through the intimate gesture of smelling his sweater, the dream-ego simultaneously attempts to conceal the stool and maintain distance, reflecting an ambivalent effort to manage intense affect and protect psychological boundaries.

Dream 3 – The well

Dream vignette

In the dream, a man opens a door and behind it there is a very deep well. It is filled with a strange warm substance, almost like mud or thermal water. I put my foot into it while the man explains that the well has many layers. As I look deeper inside, frightening images begin to appear, including skulls and other dark symbols. I suddenly become afraid that something from below might bite my foot, so I quickly pull my leg out.

When I look at it, my foot is swollen and red. I feel frightened and realise that going deeper into the well would be dangerous. I decide that I cannot continue and try to leave as quickly as possible.

Clinical context

This dream emerged during a phase of therapy in which Louisa had begun to reflect more intensively on the deeper origins of her relational patterns. At the time, she had recently ended a turbulent relationship and had started to explore how earlier family experiences might have shaped her repeated involvement in emotionally destabilising partnerships.

Particular attention in therapy had been given to Louisa’s relationship with her father, which she described as emotionally unpredictable and at times overwhelming. She experienced him as suspicious, intrusive, and psychologically unstable during her childhood. The dream appeared during a period in which these relational themes were beginning to surface more explicitly in the therapeutic process.

Patient associations

In session, Louisa associated the well with something very deep and layered, describing it as containing multiple hidden levels that she did not yet fully understand. She spontaneously linked the image to transgenerational themes, suggesting that the material represented in the well might extend beyond her current relationship and connect to earlier family dynamics.

Louisa reflected that the difficulties she had experienced in her recent relationship might therefore not only be related to romantic attachment but also to deeper relational patterns connected to her father. She noted that the dream gave her the feeling that she was not yet ready to descend fully into these layers.

Reflecting on this in therapy, Louisa described the experience in the following way: “It felt as if John came close to layers in me that were not meant to be entered. What he stirred up inside me was overwhelming. There were moments when I looked at him and felt as if it was my father looking back at me”.

The moment of pulling her foot out of the well felt to her like a protective reaction – a recognition that approaching these deeper psychological layers might currently feel too dangerous or overwhelming.

Psychodynamic interpretation

From a psychodynamic perspective, the dream can be understood as an encounter with emerging unconscious material that is experienced as both compelling and threatening. The image of the deep, layered well may symbolise the depth of unresolved relational experiences that were beginning to surface in therapy, particularly those connected to earlier family dynamics.

The appearance of disturbing imagery within the well suggests that approaching these psychological layers evokes intense anxiety and feelings of danger. Such imagery may reflect the emotional charge associated with previously avoided relational experiences, including memories linked to Louisa’s relationship with her father.

Within the therapeutic context, the dream can therefore be understood as reflecting a moment in which deeper psychological material begins to move closer to conscious awareness. At the same time, the strong affective response suggests that the integration of these experiences remains challenging, indicating that the patient’s capacity to tolerate and process such material is still in development.

Dream-ego functioning

The dream-ego initially approaches the well and tentatively engages with its depth, indicating curiosity toward emerging unconscious material. However, when anxiety intensifies, the dream-ego withdraws and leaves the situation, suggesting a protective regulation of psychological exposure when affect becomes overwhelming.

Dream 4 – The horse

Dream vignette

I am on a school trip where a group of us are supposed to go horseback riding. I walk around anxiously because I cannot find a suitable horse for myself. I want a beautiful, tall horse, not a small pony.

Eventually, the owner tells us that some special horses are still available upstairs. When I finally see the horse assigned to me, I am amazed. It is the most beautiful horse of all – tall, elegant, and very special.

I feel proud but also nervous, because the horse is young and energetic. I struggle to prepare it for riding and worry that I may not be able to control it.

While I am still trying to get everything ready, time passes and the others have already left for the ride. Soon it begins to rain, and I realise that I may not get the chance to ride the horse at all.

Clinical context

This dream appeared during a later phase of therapy, when Louisa had begun to reflect more consciously on her relational patterns and was attempting to reorganise aspects of her personal life following the breakup of the relationship.

At this stage, she described a growing wish to regain autonomy and reconnect with her own desires and life direction. At the same time, she continued to experience anxiety about whether she would be able to sustain this emerging independence without falling back into relational dynamics that had previously felt destabilising.

Patient associations

In the session, Louisa described the horse as something extremely valuable and powerful that she had been waiting for. She emphasised that she did not want a small pony but a strong and beautiful horse, which she associated with a desire for something meaningful and authentic in her life. As she reflected, “I finally got exactly the horse I wanted”.

At the same time, she noticed that the horse appeared young and difficult to control. This made her feel both proud and anxious. She associated this ambivalence with her own growing sense of independence, which felt exciting but also frightening. She explained, “I was afraid I wouldn’t be able to handle it”.

Louisa also reflected on the frustration in the dream: despite finally receiving the horse she wanted, she struggled to prepare it, and by the time she was ready, the opportunity seemed to pass. She described this experience as feeling that “I wasn’t ready, even though this was what I had wanted all along”.

Psychodynamic interpretation

From a psychodynamic perspective, the dream appears to represent a transitional moment in Louisa’s psychological development. In contrast to earlier dreams characterised by vulnerability, shame, and perceived threat, the imagery here centres on themes of vitality, aspiration, and emerging autonomy.

The horse may symbolically represent instinctual energy and the possibility of a more authentic and self-directed life. At the same time, its youth and powerful energy introduce the theme of emotional intensity that may be difficult to integrate. This ambivalence mirrors Louisa’s waking experience of autonomy as both desirable and anxiety-provoking.

The obstacles that arise before the ride begins – the difficulty in preparation, the passing of time, and the onset of rain – may symbolically reflect the fragile nature of this developmental transition. Although the wish for independence and self-direction is becoming clearer, the process of consolidating these changes remains uncertain and vulnerable to disruption.

Within the therapeutic context, the dream may therefore reflect Louisa’s ongoing efforts to reorganise her sense of self after the destabilising relationship, while gradually developing greater emotional autonomy and self-regulatory capacity.

Dream-ego functioning

In this dream, the dream-ego actively seeks and recognises a desired object, indicating an increased level of agency compared to earlier dreams. At the same time, the difficulty in preparing and controlling the horse reflects the ongoing challenge of integrating newly emerging autonomy and emotional energy.

Dream 5 – The woman on the ocean

Dream vignette

I am working in a place that feels like a nursing home. The rooms are crowded and filled with unpleasant smells. At one point an elderly woman has soiled herself and the nurses are trying to clean her. I feel uncomfortable and try to avoid taking part.

Later I find myself in a very open, bright space where a charismatic woman stands in front of me. She seems almost like a powerful or spiritual figure. She stretches out her arms and invites me to come closer. I feel that I can trust her. Soon after, I am on a small wooden raft with her on a dark ocean. She lies calmly on the raft while I move around restlessly. I suddenly realise that I am able to fly. I rise high into the sky and look down at the ocean below. When I descend again, I suddenly fall through the water surface and sink into the dark ocean. I feel intense fear and see the silhouette of a large sunken ship. After a moment of panic, I manage to return to the surface and back to the raft.

Clinical context

At the time of the dream, Louisa described feeling emotionally destabilised while simultaneously sensing the possibility of new perspectives emerging in therapy. The therapeutic work had gradually shifted from acute relational crises toward broader questions of identity, autonomy, and meaning.

During this period, Louisa described a growing sense that she was beginning to access previously avoided emotional material, while simultaneously attempting to develop new internal resources for regulating anxiety and vulnerability.

Patient associations

In session, Louisa described the woman in the dream as a powerful and trustworthy presence. She associated this figure with guidance, wisdom, and a sense of inner authority. The encounter with the woman felt reassuring and safe in contrast to the tension and discomfort that characterised the earlier part of the dream. As she reflected, “I felt that I could completely trust her”.

Louisa also reflected on the contrast between the woman’s calmness and her own restlessness on the raft. She experienced the ability to fly as an exhilarating sense of freedom and expansion, although this was quickly followed by fear when she unexpectedly fell into the dark ocean.

She associated the descent into the water with encountering something unknown and potentially overwhelming, but emphasised that she was ultimately able to return to the surface. She remarked, “I was frightened, but I wasn’t trapped. I could come back”.

Psychodynamic interpretation

From a psychodynamic perspective, the dream may reflect a significant shift in the patient’s internal organisation. In contrast to earlier dreams characterised by vulnerability, shame, and perceived threat, the imagery here introduces themes of guidance, trust, and psychological expansion.

The appearance of the calm female figure may symbolise the emergence of a stabilising internal presence associated with guidance, authority, and emotional containment. Within the therapeutic context, this figure may represent the patient’s developing capacity to rely on internalised supportive representations when encountering previously overwhelming emotional material.

The dark ocean and the image of the sunken ship evoke deeper layers of unconscious experience, suggesting that previously avoided psychological material is becoming more accessible within the therapeutic process. Rather than representing only danger, these images may reflect the depth and complexity of emotional experiences that the patient is gradually beginning to integrate.

In this sense, the dream may illustrate a phase in therapy in which Louisa is developing greater psychological stability while approaching previously threatening inner experiences. The dream imagery therefore reflects a growing capacity for emotional integration and the gradual consolidation of internal regulatory resources.

Dream-ego functioning

Here the dream-ego demonstrates expanded exploratory capacity by flying and approaching deeper emotional layers represented by the ocean. Importantly, after the frightening descent, the dream-ego succeeds in returning to the surface, suggesting an emerging ability to tolerate intense affect while maintaining psychological coherence. This pattern is consistent with the broader developmental trajectory of dream-ego functioning observed across the dream series as shown in Table 3.

Discussion

Main findings

The present case study illustrates how longitudinal dream analysis may provide a sensitive window into evolving affect regulation and relational self-regulatory processes during psychodynamic psychotherapy in the context of chronic somatic illness.

Across the first year of analytic treatment, the patient’s dream narratives displayed a coherent pattern of transformation. Early dreams were characterised by vulnerability, immobilisation, and limited capacity for autonomous action, whereas later dreams increasingly portrayed the dream-ego as capable of evaluating threat, withdrawing from destabilising situations, and engaging more actively with emotionally significant experiences.

These changes in dream organisation occurred alongside observable shifts in waking functioning. Over the course of therapy, the patient gradually developed greater awareness of her own needs, improved tolerance for relational ambivalence, and increased capacity to establish interpersonal boundaries. Although these developments ultimately led to the termination of a longstanding romantic relationship, the separation was experienced not as collapse but as a difficult yet self-protective reorganisation.

The parallel development of waking relational autonomy and increasing dream-ego agency is consistent with a growing body of clinical dream research suggesting that dream structures may reflect broader psychological functioning (Glucksman, 2001; Pesant & Zadra, 2004). Within structural dream analysis, the degree of agency exhibited by the dream-ego has been conceptualised as a marker of ego strength and adaptive capacity. As outlined by Roesler (2018), increasing dream-ego activity may parallel clinical progress during psychotherapy.

Similarly, qualitative investigations of therapeutic dream change have shown that dream-ego behaviour may evolve from states of helplessness or immobilisation toward increasingly active coping strategies as treatment unfolds (Ellis, 2016). The present case extends these observations by illustrating how such transformations may emerge longitudinally within analytically oriented psychotherapy and how they may coincide with the patient’s developing capacity for relational differentiation.

Taken together, these findings suggest that shifts in dream-ego positioning – from immobilisation toward agentic engagement – may reflect underlying changes in implicit relational regulation. Longitudinal dream analysis may therefore offer a valuable phenomenological indicator of therapeutic change processes that are not always immediately accessible at the level of conscious reflection. From a psychotherapy process perspective, these findings illustrate how implicit regulatory capacities may evolve through iterative interactions between relational experience, affective processing, and symbolic representation.

Dream-ego development and affect regulation

The longitudinal changes in dream-ego functioning observed across the dream series may reflect broader changes in affect regulation and psychological integration over the course of psychotherapy. Within Jungian dream research, the dream-ego is understood as the experiential centre of the dream narrative through which the dreamer encounters and responds to emotionally significant situations (Roesler, 2018). Contemporary Jungian theory further conceptualises implicit relational organisation as developing through internal working models and emotionally encoded patterns of experience (Knox, 1999, 2001). Within this developmental framework, the degree to which the dream-ego can act, respond to threat, and influence the unfolding dream situation may be interpreted as reflecting the dreamer’s current psychological resources for engaging with emotionally salient experiences (Roesler, 2018).-

Table 3.

Developmental patterns of dream-ego functioning across the dream series.

Dream	Dream-ego functioning
Puppy dream	Overwhelmed by a chaotic environment but performs a small regulatory action (closing the aquarium), suggesting an early capacity to establish boundaries
Stool dream	Caught in an attachment-avoidance conflict, attempting simultaneously to approach the partner and conceal feelings of shame and exposure
Well dream	Tentatively explores deeper psychological material but withdraws when anxiety intensifies, indicating defensive regulation of emotional exposure
Horse dream	Demonstrates increased agency by actively seeking a desired object, although the integration of this emerging autonomy remains fragile
Ocean woman dream	Shows expanded exploratory capacity and affect tolerance, successfully returning to psychological equilibrium after encountering threatening material

In early phases of therapy, the patient’s dreams frequently depicted immobilisation, external rescue, or overwhelming threat. Such configurations may reflect difficulties in recognising relational danger and asserting protective distance within waking relational contexts. As therapy progressed, however, dream scenarios increasingly portrayed the dream-ego as capable of evaluating relational threat and withdrawing from harmful situations.

This pattern parallels observations from clinical dream research showing that dream-ego behaviour may evolve along a continuum from freezing and helplessness toward increasingly active coping responses as psychological integration develops (Ellis, 2016). Similar findings have been reported in studies examining dream change during psychotherapy, where increased dream-ego initiative and problem-solving behaviour were associated with improvements in psychological functioning (Glucksman, 2001; Pesant & Zadra, 2004).

The present findings may also be interpreted within contemporary affective neuroscience models, which propose that dreaming contributes to the reprocessing and integration of emotionally salient experiences during sleep (Lane et al., 2015; Walker & van der Helm, 2009). From this perspective, the gradual changes observed in dream-ego functioning across psychotherapy may reflect the progressive updating of implicit emotional memory networks through repeated cycles of emotional reconsolidation, whereby previously dysregulated affective experiences become increasingly integrated (Kandel, 2001; Lane et al., 2015).

In the present case, the evolving capacity of the dream-ego to recognise danger, withdraw, and re-establish equilibrium may therefore represent the phenomenological trace of increasing affect regulation and relational differentiation within the therapeutic process. From a Jungian perspective, such changes may also be understood as reflecting a gradual reorganisation of the ego-Self relationship, referring to a more integrated relationship between conscious psychological functioning and broader unconscious regulatory processes (Jung, 1960).

Dreams as indicators of affective and bodily regulation

Beyond their symbolic and narrative functions, dream processes may also reflect ongoing affective and bodily regulation. Dreaming has been conceptualised as an internally generated experiential state in which emotionally salient experiences can be reactivated and reorganised (Nir & Tononi, 2010), supported by neurophysiological conditions involving limbic activation and reduced prefrontal control (Dang-Vu et al., 2010).

From a psychosomatic perspective, these processes may be particularly relevant in chronic conditions characterised by strong interactions between emotional stress and bodily regulation. Inflammatory bowel disease is increasingly understood within the framework of the brain-gut axis, which emphasises bidirectional communication between central nervous system processes, autonomic regulation, immune responses, and intestinal inflammation (Bonaz & Bernstein, 2013). Psychological stress may influence disease activity through neuroendocrine and autonomic pathways that affect inflammatory processes and bodily functioning (Günther et al., 2021).

In the present case, periods of heightened relational stress were subjectively associated with exacerbations of gastrointestinal symptoms, while phases characterised by increasing relational autonomy and emotional differentiation were accompanied by a reduction in anxiety-related somatic burden. Although causal inference cannot be drawn from a single case, this temporal co-occurrence is consistent with models linking stress regulation and braingut functioning in chronic inflammatory conditions (Bonaz & Bernstein, 2013; Günther et al., 2021).

Dream material may therefore be understood not only as symbolic representation but also as a phenomenological indicator of ongoing regulatory processes operating at the interface between affective and bodily systems.

Clinical implications for psychotherapy in anxiety and psychosomatic disorders

The present findings may hold relevance for psychotherapeutic work with patients presenting with anxiety and psychosomatic conditions in which emotional stress interacts with bodily regulation.

From a psychodynamic perspective, anxiety – particularly persistent worry – may function as a defensive process that helps avoid more distressing relational or emotional themes (Crits-Christoph, 2002). Psychodynamic-interpersonal formulations further emphasise that anxiety often develops within recurrent relational configurations shaped by earlier attachment experiences, which may become reactivated in later relationships (Crits-Christoph, 2002).

In the present case, the patient’s anxiety appeared closely linked to such relational patterns. Her involvement with an older partner reactivated earlier dynamics associated with her relationship with her father, contributing to heightened emotional vulnerability and persistent relational insecurity. At times, this overlap was experienced directly, as reflected in her report of “seeing her father looking back” at her partner.

Such relational reactivation processes may be particularly relevant in psychosomatic conditions, where emotional stress and bodily regulation are closely intertwined. Patients with chronic illness frequently report heightened sensitivity to bodily signals and reduced sense of control, which may be exacerbated by relational stress. In this case, periods of relational instability were subjectively associated with increased gastrointestinal distress, consistent with models of brain-body interaction (Bonaz & Bernstein, 2013; Günther et al., 2021).

Psychotherapeutic work that facilitates increased tolerance of emotional states, improved recognition of relational patterns, and greater self-directed agency may therefore contribute not only to psychological change but also to improved systemic stress regulation.

In this context, dream analysis may offer clinicians a particularly sensitive window into implicit affective and relational processes that are not yet fully accessible at the level of conscious reflection. Across the dream series, the strengthening of dream-ego agency paralleled the patient’s growing ability to recognise destabilising relational dynamics and to establish psychological distance from a relationship experienced as emotionally harmful.

Systematic attention to dream material may thus enrich psychodynamic psychotherapy by providing insight into evolving processes of affect regulation, relational differentiation, and emerging autonomy.

Limitations and future directions

Several limitations should be acknowledged. As a single-case qualitative study, the findings cannot be generalised and should be considered exploratory and hypothesis-generating. Dream reports rely on retrospective narratives, and the relationship between dream experience and underlying neurobiological processes cannot be directly assessed. In addition, the interpretation of dream material inevitably involves a degree of clinical subjectivity, although efforts were made to ground interpretations in the patient’s associations and the therapeutic context.

Future research could combine longitudinal dream analysis with multimethod approaches integrating clinical observation with physiological or neurobiological measures. Larger qualitative or mixed-method studies examining dream-ego development across psychotherapy processes may further clarify the relationship between dream structure, affect regulation, and therapeutic change. In addition, the dual role of therapist and researcher may have influenced both the selection and interpretation of the material, despite efforts to ground the analysis in the patient’s associations and documented clinical context. Furthermore, the interpretative framework reflects a specific theoretical orientation, which may influence the understanding of the observed processes.

Conclusions

The present case study highlights the potential value of longitudinal dream analysis as a process-sensitive window into evolving affect regulation and relational reorganisation during psychodynamic psychotherapy.

Across the therapeutic process, the progressive emergence of more agentic dream-ego functioning paralleled Louisa’s increasing ability to recognise destabilising relational dynamics, establish interpersonal boundaries, and disengage from a relationship that had maintained significant emotional distress.

This development also reflected her growing capacity to recognise the painful relational paradox she had described earlier, in which the same person could be experienced both as a source of comfort and of emotional injury.

Rather than representing merely symbolic narrative variation, the observed transformations in dream organisation may reflect deeper changes in implicit relational and affective regulation. Within psychodynamic perspectives on anxiety, such changes can be understood as the gradual reorganisation of internalised relational expectations and defensive patterns that previously maintained chronic worry and relational insecurity.

In this sense, dream material may offer clinicians a unique experiential perspective on implicit regulatory processes unfolding during psychotherapy. When interpreted within contemporary frameworks from clinical dream research, affective neuroscience, and psychodynamic theory, shifts in dream-ego functioning may provide a valuable phenomenological indicator of emerging affect tolerance, relational differentiation, and psychological autonomy.

Finally, in the context of chronic somatic illness, these regulatory changes may carry additional clinical relevance. Although causal conclusions cannot be drawn from a single case, the convergence between improved affect regulation, increasing relational autonomy, and reduced anxiety-related somatic burden in Louisa’s case is consistent with emerging models linking emotional regulation and systemic stress processes in chronic illness.

These processes may also be understood within a Jungian framework as reflecting the gradual integration of unconscious material and the transformation of underlying relational complexes (Jung, 1960).

Availability of data and materials

Data supporting the findings of this study are available from the corresponding author upon reasonable request.