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Poor sleep is a common feature in post-traumatic stress disorder (PTSD), occurring 90% of the time; 70% of people with PTSD experience recurring nightmares (Ranney et al., 2022). Nightmares may be about death or risk of harm or death, being left behind or lost, or being exposed and vulnerable in some other way. How to work with nightmares in therapy is very individualized, but here are some evidence-based approaches that can be woven into therapy to reduce the frequency and intensity of horrific images that recur during sleep.
First, applying sleep restriction and sleep hygiene (part of cognitive behavioral therapy (CBT) for insomnia) has been found to reduce nightmares, but it seems this is only temporary. In one study with veterans who had PTSD, nightmare reduction was not maintained at a six-month follow-up, suggesting that training sleep-wake rhythms may be a good place to begin but is not enough to treat nightmares. Addressing the trauma and the deeper story of the nightmare seems to lead to longer-lasting outcomes, which will be described in more detail below (Ranney et al., 2022).
Second, progressive muscle relaxation and other ways to allow the nervous system to relax deeply can be beneficial for sleep, but again, for nightmares, it is more effective when used in combination with other therapies, such as narrative therapy. Narrative therapy can help clients express untold parts of their story, connect emotional and somatic experiences, integrate and construct meaning in a larger life story context, and eventually retell their survival story in a new light.
Applying narrative therapy to nightmares has been called image rehearsal therapy. A meta-analysis of image rehearsal therapy for post-trauma nightmares found this approach reduced nightmares and improved general sleep quality. The effects were maintained up to a year later (Casement and Swanson, 2012).
Image rehearsal therapy includes direct exposure (when the client is ready) to the nightmare by speaking it aloud or writing it down in detail, sharing it with the treating clinician, and then reconstructing a new preferred ending to the nightmare. This is followed by rehearsing the new chosen ending, using a person’s active imagination, until things begin to shift.
The basic components of image rehearsal therapy include writing a narrative that includes a change to some aspect of a selected nightmare and then practicing daily imaginal rehearsal of the new dream narrative (Lely et al., 2019; Aurora et al., 2010). Some examples of what to change about the nightmare story can include adding prompts to oneself within the dream, inserting an object of meaning to assist oneself in the dream, transforming the threat of the nightmare from terrorizing to benign, observing the nightmare at a distance as if watching on TV or movie screen, or rewriting the one’s own role in the nightmare from helpless to someone who resolves or overcomes the situation. (Some clinicians integrate this with active imagination Jungian dialogue.)
In summary, the steps for image rehearsal therapy include:
- Narrate the nightmare with central elements out loud in therapy or writing. Get as detailed as possible, and be sure to have support while doing this.
- After adequate time and effort have been spent on step 1, rewrite the story with a different, neutral, or positive ending.
- Then, set an intention for re-dreaming it with this new ending. (This works surprisingly well in my experience with clients.)
- Observe any small change in the nightmare as things begin to shift and process what occurs with a trusted clinician. This can increase a sense of agency within the nightmare, and it continues to shift.
For those who struggle to talk about frightening images in a nightmare, image rehearsal therapy may be combined with art therapy to engage people on a nonverbal level and express scary images and experiences. The more they are expressed, terrorizing memories and images lose their power and become more neutral. Later, sharing what surfaces from art therapy in a safe group setting can be especially healing (Haeyen S. and Staal M., 2021).
References
Ranney, R. M., Gloria, R., Metzler, T. J., Huggins, J., Neylan, T. C., & Maguen, S. (2022). Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 18(7), 1831–1839. https://doi.org/10.5664/jcsm.10002
Casement, M. D., & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical psychology review, 32(6), 566–574. https://doi.org/10.1016/j.cpr.2012.06.002
Lely JCG, Smid GE, Jongedijk RA, W Knipscheer J, Kleber RJ. (2019). The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. Eur J Psychotraumatol. Mar 25;10(1):1550344. doi: 10.1080/20008198.2018.1550344. PMID: 31007868; PMCID: PMC6450467.
Aurora, R. N., Zak, R. S., Auerbach, S. H., Casey, K. R., Chowdhuri, S., Karippot, A., Maganti, R. K., Ramar, K., Kristo, D. A., Bista, S. R., Lamm, C. I., Morgenthaler, T. I., Standards of Practice Committee, & American Academy of Sleep Medicine (2010). Best practice guide for the treatment of nightmare disorder in adults. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 6(4), 389–401.
Haeyen S, Staal M. Imagery Rehearsal Based Art Therapy: Treatment of Post-traumatic Nightmares in Art Therapy. Front Psychol. 2021 Jan 14;11:628717. doi: 10.3389/fpsyg.2020.628717. PMID: 33519657; PMCID: PMC7840539.
