Imagery Rehearsal Therapy to Treat Nightmares With PTSD

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Imagery rehearsal therapy (IRT) is a cognitive-behavioral treatment for reducing the number and intensity of nightmares, such as those experienced by people with posttraumatic stress disorder (PTSD). Nightmares or terrifying dreams are among the most common PTSD symptoms. IRT focuses directly on helping to make nightmares less intense for people with PTSD.

If you've ever had a nightmare, you probably woke up just at the moment when it felt most frightening. That's because, as you probably know, the intensity of a nightmare usually builds until the sleeper is too terrified to continue--and wakes up.

In IRT treatment, you're helped to reimagine your nightmares with different, less frightening outcomes. The goal is to "reprogram" your nightmares to be less terrifying if and when they occur again.

How Imagery Rehearsal Therapy Works

In IRT, your therapist first provides you with background information on sleep and nightmares to "set the scene" for learning to manage them. Then, working with your therapist, you:

  • Create detailed, nonfrightening endings for nightmares you've had repeatedly
  • Write down and rehearse the nightmares with the new endings
  • Learn how to monitor your nightmares so you know how well your IRT treatment is working

Often a person with PTSD has already thought about whether it might help to reimagine and "defuse" nightmares so they're less frightening. That can help make starting IRT feel more comfortable and hopeful, but it isn't necessary for the technique to be successful.

Could This Therapy Be Upsetting?

Your therapist will likely ask you to begin your IRT with one or more of your less-frightening nightmares. Why? To build your confidence and help keep you from being frightened by the nightmares again as you bring them into your waking hours.

The goal is not to trigger emotional responses. Instead, it's to help you view your nightmares with as little emotion as possible. Typically, the therapist will start the rehearsal process by saying something to help you stay calm, such as, "Now, we'll rehearse the dream--not the nightmare." Think of it as a "crawl before you walk" approach.

How Long Does It Last?

It's important to be aware that IRT is not an open-ended therapy. It lasts for a specific length of time because it's focused only on nightmares, which are just one symptom of PTSD. If you are having a number of PTSD symptoms, consider looking into more broad-based treatments, such as exposure therapy.

Is This Approach Right for You?

You can work with IRT alone with your therapist or as part of group therapy.

Although the usual goal of IRT is achieving less frightening endings to nightmares, different people with PTSD may have different ideas about what they want from it. For example, you may want to change an entire nightmare, or a large portion of it, while someone else wants to reimagine only a few small details. A therapist will work with you to choose the IRT approach that best fits your needs.

3 Sources
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  1. Kunze, A.E., Lancee, J., Morina, N. et al. Efficacy and mechanisms of imagery rescripting and imaginal exposure for nightmares: study protocol for a randomized controlled trialTrials. 2016;17:469. doi:10.1186/s13063-016-1570-3

  2. El-Solh AA. Management of nightmares in patients with posttraumatic stress disorder: current perspectivesNat Sci Sleep. 2018;10:409–420. doi:10.2147/NSS.S166089

  3. American Psychological Association. Clinical practice guideline for the treatment of posttraumatic disorder. Prolonged exposure.

By Matthew Tull, PhD
Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.