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10:56:56 
2024-06-23 
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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. 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.
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.
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. 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.)
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