Nightmare Therapy
27 November 2011
DREAMWORK COLUMN FOR COUNSELLORS by Margaret Bowater, MA
Published in NZAC Newsletter, “Counselling Today,” Sept 2010, Vol.31: 1, pp 33-35.
ARTICLE 19: Using Imagery Rehearsal Therapy with Nightmares
In my last Column I wrote about a CBT method of working with dreams in general, citing an article on the subject in the journal Dreaming [Montangero, 2009]and an article written by Aaron Beck, republished in a recent book, Cognitive Therapy and Dreams (Rosner, 2004). I want to follow that by summarizing and adding to a particular process from another chapter in Rosner’s book, this time by Dr Barry Krakow, a sleep specialist in New Mexico, USA: “Imagery Rehearsal Therapy for Chronic Post-Trauma Nightmares: A Mind’s Eye View.”
Krakow explains that his primary focus was initially on the treatment of sleep disorders, “because those with chronic nightmares almost invariably suffer from insomnia,” which together can cause chronic sleep-disordered breathing patterns, which are likely to undermine mental health. He quotes a figure of 4% to 8% of the general population in USA suffering from Chronic Nightmare Disorder; and I would expect a similar proportion in NZ.
Our natural imagery system
Krakow describes how we tend to take our natural imagery system for granted until it becomes disturbed. “An intact and viable imagery system provides humans with the capacity to dream, daydream, picture solutions to problems, get new ideas, and … integrate information, facts and knowledge about our thoughts and feelings into snapshots or a series of brief pictures worth far more than a thousand words” (p.90).
In contrast, he observes, the imagery system malfunctions in trauma sufferers who develop chronic nightmares. Are these chronic nightmares a symptom of mental illness, or could they be a kind of habit that could be treated separately? So in 1994 his sleep research programme tested IRT (Imagery Rehearsal Therapy) on the nightmares of trauma patients, and found that it not only decreased their nightmares but also improved sleep and post-traumatic symptoms generally. After that his team developed a systematic programme to teach sufferers how to use IRT for themselves, including several hundred survivors of sexual assault, crime and disaster.
They observed that most chronic nightmare sufferers developed insomnia as a side-effect, which tended to cause frequent mini-awakenings, leading often to disordered breathing, which in turn disrupted the REM-sleep phases that are “necessary for healthy and successful processing of information, memory and emotions” (p.92). In other words, severe unresolved trauma tends to produce chronic nightmares which may so disturb sleep that the sufferer’s general mental functioning is seriously impaired. What Krakow’s team found, rather to their surprise, was that direct treatment of the nightmares could make a significant difference to mental and physical health.
Krakow freely acknowledges that many people discover the technique using their own resources, and cure their nightmares by simply deciding to change the story. So his technique is really a systematization of folk wisdom, particularly for the benefit of more severe cases.
Krakow’s model
His basic outline teaches sufferers to practise the skill first on “easier” nightmares:
- select a moderately disturbing dream, not a full trauma-dream;
- change it in any way you wish, eg writing a new version;
- rehearse the new story for a few minutes each day;
- continue for several days, then do another nightmare – not more than two a week.
Some trauma sufferers may object that they can’t change the dream, because it reflects what actually happened. Krakow simply encourages them to use their imagination, but avoid rehearsing the actual trauma. Once they begin making changes, “IRT jump-starts a natural human healing system that was previously dormant” (p.97), and begins to affect not only their nightmares but also their approach to daytime problems.
In such cases I use my own explanation, agreeing that history can’t be changed, but you don’t have to let the memory of that event keep on re-victimising you. Particularly in the case of personal assault, do you want to let the perpetrator go on dominating your mind?
In some ways, my attitude is derived from the existential philosophy of Viktor Frankl, who even in the horrors of a Nazi Concentration Camp refused to let his mind be subjugated.
Objections to Imagery Change
Some of Krakow’s patients resisted treatment of their nightmares because of believing that they had to be cured of PTSD before the nightmares could change. So he drew a timeline on the board to show that “nightmares and insomnia are very common in the first few weeks after traumatic exposure, but that the majority of traumatized individuals recover without developing chronic PTSD, nightmares or insomnia” (p.99). So why did some people still have them 20 years later? Could the nightmares have become a learned habit which could be unlearned? (I would suggest they are on a neural pathway, strengthened by repetition.)
Krakow observed that some people also thought that their nightmares kept repeating as a symptom of unfinished business, holding that the business had to be resolved first, or other symptoms would appear. Yet most of Krakow’s patients recovered using IRT, unless they had extremely complex problems with mental illness. One group of patients, however, tended to drop out of treatment near the start, comprising one-third of the sexual assault survivors in his largest study (p.105). He gives no reason for this, but notes on the next page that there was a high success rate with the others, which he attributes to the improvement in their sleep. My own experience suggests that many sexual assault survivors really do need to resolve other issues first; their very identity may have been shaken.
An important point to notice is that nightmares after trauma have a normal tendency to change, “as if the dreams themselves were working out some aspect of the emotional turmoil generated by the trauma” (p.103). Getting stuck then is like the needle on a broken record.
War veterans
Here I am reminded of the work of Harry Wilmer (reported in his article in Barrett, 1996) when working with Vietnam veterans in 1981. Early in his research, he identified three categories of nightmares, which represented stages of recovery. Category 1 nightmares were largely direct replays of horrific memories; in Category 2 there was a growing mixture of fantasy which altered the memories, so that they no longer felt so realistic; and in Category 3 the emotional intensity had largely discharged, so that the memories were mixed with more mundane elements and a story of survival. Some of the most difficult dreams to resolve were those in which the dreamer was carrying guilt about his own behaviour.
I have discussed dreams with a veteran soldier I will call Max, who, on returning to civilian life, found himself subject to a recurring trauma-based nightmare:
Dream report: Guilty of Murder
I had an image of a corner of the shrubbery in our garden, near the fence, and I knew with dread that I had murdered someone and buried him secretly there. I could smell the sweet rotting smell of the body, and I felt very guilty.
At least twice after I woke up, I was so uncertain of whether this was true or not, that I actually got out of bed and went down the garden without telling my wife, to check the ground. I had a huge sense of relief at finding the garden undisturbed. The smell of course is based on real memory.
I had killed men in combat situations, but never elsewhere. I was shocked when I realised that I was in fact capable of murder like this. The dream recurred several times with the same guilt and dread, until I had checked it often enough to know for sure that it wasn’t true. It hasn’t happened again, but I remember the power of the delusion at the time, and the awfulness of not knowing my own reality.
This dream had enough elements of reality to classify it as Category 1; but to resolve it required Max to use more than imagination; he needed to replace the dream scene with the actual image of his garden, while also re-adjusting his personal values from military conditioning to civilian morality.
Imagery change by re-entering the dream
Max also told me how he dealt with another nightmare, again by taking immediate action, but this time by re-entering the dream intentionally to confront the fear. The issue was that he was about to begin personal therapy, and unconsciously feared that it would reveal some kind of monster lurking inside him. He had had many nightmares in childhood, probably related to severe bouts of pneumonia, which may account for his level of terror.
Dream report: Unknown Presence
I dreamed that I was lying in bed in the bedroom I had had as a child. The door was slightly ajar. I became aware of what seemed to be a presence coming up the stairs – and I felt a powerful fear of something unknown approaching. I woke up sweating, with a sense of utter terror, tightness in my chest and throat, almost tears in my eyes, and feeling totally paralysed.
Wow! I thought, what a nightmare! I went over it in my mind, and to my surprise the physical sense of terror repeated – and then again – though I knew in my head that there was no need to be afraid in reality. So I thought about what to do, if this were happening for real. My philosophy is always to do something, take control of the situation. So I decided I would open the door, and go and see what was there.
I let myself go back to sleep again, and I was back in the bedroom – and the whole sense of terror repeated. This time in my dream I got out of bed, opened the door and went down the stairs to see what was there. At the bottom, I found myself standing on the edge of a stone jetty, looking out at a great black stretch of still water, glimmering faintly, as far as the eye could see. There was no threat there. I felt quite calm, and thought, Oh, of course, with a sense of relief, and the dream dissolved.
When I woke in the morning, I remembered it all, and felt amazed at how I had worked with the nightmare. I have never felt that kind of terror since the nightmares I had as a young child, from about 3 to 5. I used to wake up screaming. I can’t connect it with any memories of people, or death, or anything that happened.
Rehearsing a new way of acting
Not many of us would be able to act as rapidly as Max did to change the ending of a night-mare, but I have often worked with a client or trainee who was presenting a recurring dream or nightmare to create a new ending, which at least gets them out of perceived danger while they figure out what it relates to, before imagining a different way to act in the dream-story. Once they understand how the dream is reflecting their experience, and even challenging them to find a new way forward, most people readily create a new ending, and may not even need to rehearse it. The nightmare simply loses its power from then on.
With survivors of sexual abuse who have been systematically disempowered, the process may take longer, while they begin to reclaim their integrity. In such cases there are often many dreams to work with over time, gradually consolidating their autonomy and shedding the script beliefs that have blocked their recovery. One young woman I worked with over two years set herself her own goal in the latter stage of confronting the abusive father who had dominated her youth. She not only imagined how she would like to speak her truth to him without crying, but practised it several times in chair-work, including his expected resistance. Then came the night when she actually dreamed the full confrontation – and decided to act on it straight away! She reported back how the feeling of power in the dream stayed with her and she was able to manage herself successfully through the event, which shifted the balance between them from then on.
Using life-experience
Another woman had a similar experience of power in dealing with her abuser. Maggie, 66, had entered counselling to deal with a parallel issue of being emotionally abused, when a buried memory returned acutely through a dream. She had also just been told about cellular memory.
Dream report: Memory of Rape
(After a period of dreaming) I found myself in bed being painfully raped. I was protesting but the man on top of me seemed much bigger than I was. I couldn’t see his face. The pain was so excruciating that it woke me up.
I felt small, like a child, and suddenly remembered that I had in fact been raped when I was 4 1/2, by the teenage babysitter. It was exactly the same pain, and it was still going on in my body after the dream. I had a sense that his presence was still there, though I knew I was physically alone, so I spoke out loud and told him he had no right to use me or overpower me – and he disappeared!
But I was still in pain. I curled up in a foetal position and cried a bit, and prayed to God to take the pain away. (I have a Christian faith.) After a while it went and I turned over and went back to sleep. In the morning I felt quite normal, and knew that it was a memory, not a new pain to take to a doctor. I told my counsellor about it the next day – the first time I had told anyone. I felt lighter, as if there was space in my body instead of heaviness – I did actually lose half a kilogram that week!
During the 60 years that had passed since the rape occurred, Maggie had buried the experience, telling no one. But she had also matured in personality, no doubt learning how to stand her ground against other potential abusers, and was actually seeking to further empower herself when the memory returned, so she was ready immediately to change the ending.
Conclusion:
The power of mental imagery to influence our lives for better or worse is enormous, and operates both consciously and unconsciously within us. Our dreams can bring it to the surface, and observing them creates clearer awareness of our inner experience.
This method of Imagery Rehearsal provides a conscious tool for shifting from negative to more positive imagery, whether slowly or quickly, in the service of both mental and physical health.
References:
Barrett,D., ed, (1996), Trauma and Dreams, Harvard University Press, Cambridge, Mass.
Frankl, V. (1946/84), Man’s Search for Meaning, Pocket Books, NY.
Krakow, B., “Imagery Rehearsal Therapy for Chronic Post-Trauma Nightmares,” in Rosner et al.
Rosner, Lyddon and Freeman (2004), Cognitive Therapy and Dreams, Springer Co., NY.