Nightmares are Easily Treatable, Though Too Few Seek Help By Leslie Ellis, PhD on 9/19/19 - 5:55 PM

Nightmares are common and distressing phenomena that often co-occur with anxiety, depression, stress and trauma, and they are one of the main symptoms of trauma-based pathology. Most people who suffer from nightmares have no idea how quick and easy it can be to stop or change their distressing dreams. Yet, in my experience, and as the literature suggests, clinicians may veer away from focusing on their client’s’ nightmares for fear of potentially making things worse, especially when those nightmares occur in the context of trauma.

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A client I will call Jill woke up with a start, her heart pounding, the fear of being chased by a dark, unknown pursuer still a fresh and very real sensation. As she looked around her bedroom, it dawned on her that she had just experienced a version of the same recurring nightmare that had haunted her since adolescence. Such dreams often revisit in times of stress. They disrupt sleep and can fill the dreamer with dark, foreboding feelings or disturbing images that persist, sending daytime thoughts down darker pathways than they might have gone.

In our therapy session, Jill and I explored the dream, first its setting which was a mix between an office building and her childhood home. The dream ended with Jill crouched on the small balcony outside one of the top-floor bedrooms with the door just opening, the dark man about to find her and try to kill her. In exploring the dream, I invited Jill to pick up a few resources along the way. For example, her gym bag at the front door brought her a feeling of strength and speed as she recalled how she used to compete in distance running. Still an athlete, she sensed how at home she feels in her body. Bolstered by this, she allowed her dream to play forward, following my instruction to simply let it unfold as if she had just pressed play on the dream scene.

When she did this, Jill opted to use her sense of power and speed to leap off the balcony and run through the air, flying away into the night. In other versions of this common pursuit nightmare, dreamers like Jill have chosen to turn and face their pursuer, and often this leads to a conversation that softens the entire encounter, bringing some peace and understanding between aggressor and dream ego. Like any true encounter, the outcome is unpredictable, but in most cases, interacting with the dream aggressor helps.

There are numerous studies demonstrating that re-scripting nightmares can be an effective way to reduce their frequency and distressing impact on the dreamer. In fact, almost any kind of imagined change is helpful. A pair of clinical trials by Krakow and his colleagues in 2000/2001 showed Imagery Rehearsal Therapy (IRT), which involves giving the nightmare a new ending and rehearsing it, to be an effective treatment for nightmares compared with waitlist controls. Since then, many other forms of nightmare re-scripting have shown similar effectiveness. It appears that almost any kind of nightmare treatment has the potential to help, providing the dreamer with a sense of control.

I attended a nightmare research symposium at the recent conference for the International Association for the Study of Dreams (IASD) in Kerkrade, The Netherlands in June 2019. Presenter Kate?ina Surovcová presented a qualitative study of the experiences of social dream sharing of nightmares. She noted that only one in 8 people sought help for their nightmares. She said people are reluctant to share nightmares for fear of being seen as crazy, and because they don’t want to burden others with the darkness of their dreams.

Another recent study, a randomized controlled trial by Carolin Schmid, compared two established imagery-based treatments and showed that all treatments are effective at reducing nightmare frequency and distress, even the control condition! In the study, which had 96 participants, Schmid compared three different imagery-based methods. The first was imagery rehearsal therapy (IRT); the second was exposure therapy, in which the client is repeatedly exposed to their nightmare imagery; and the third, an active rather than waitlist control, asked clients to imagine a safe place. Interestingly, all three methods worked equally well, and all worked with just one treatment session. So, in treating nightmares, it may be that any treatment is better than no treatment, and just one session may be enough to make a difference.

Schredl noted that in nightmare studies and clinical treatment, the distress caused by the nightmare is the most important variable, and the frequency is secondary. He said people’s attitudes toward their nightmares matter, another area where clinical intervention can be helpful. In Jill’s case, the experience of successfully flying off the balcony and away from her pursuer brought a sense of exhilaration and power, and since that session, she has not experienced the nightmare again. But even if she had, Jill said she would now be far more welcoming of it because the original scared and helpless feelings have shifted so dramatically. It is important that clinicians consider forging ahead when clients present nightmares because it appears that almost any kind of therapeutic attention to the dream might make a positive difference.


File under: Musings and Reflections