By David Joel Miller.
Then Come Nightmares.
Frequent nightmares play a major role in maintaining depression, PTSD, and other mental health problems. It is common for people to think that they need to cure the PTSD or Depression and then the nightmares will go away. The opposite approach is more likely to be productive.
Most treatments for PTSD do not target the nightmares. There are treatments for nightmares available, some as brief as three sessions. These have been shown to help reduce nightmares and promote recovery from other problems.
Treatment for nightmares has been shown to reduce symptoms of PTSD and depression.
Children also suffer from nightmare related problems. Children who are fearful because of a family problem, moves, divorces or separation develop symptoms of mental illness. “Bad dreams” are the result of the child’s out of control fear and are at the root of many childhood attention or conduct disturbances. When the child gets a good nights sleep they behave, when they don’t sleep they don’t pay attention, and they don’t mind.
Nightmares are associated with high levels of anxiety. They are fear based.
Most people who have PTSD, depression, bipolar disorder or any other diagnosis also have a co-occurring anxiety problem. Now sometimes anxiety is good, it protects you from danger. But when the anxiety circuits do not turn off the anxiety gets to be the problem rather than the solution.
We also see lots of disturbing dreams in clients recovering from substance abuse problems. Substance abuse counselors report clients sharing about drug using dreams. We have some simple interventions around those issues, but not much research has been done in this area because substance abusers, people with Bipolar Disorder and people with psychosis are routinely excluded from research studies. I believe that the treatment for nightmares will work for anyone.
The solution is to tone down that fear circuit.
Before I describe a treatment method for reducing nightmares – a word of caution, working on nightmares, especially those that maintain PTSD, can be a painful process. It is best to work with a therapist or other professional person, and you need to make sure you have a strong support system in place in case you have difficulty coping. For more on support systems see “How to develop a support system” or “How supportive is your support system?”
Taming nightmares involves three steps.
1. Learn relaxation methods.
Nightmares are fear based, and the fear persists after you awake. Sitting thinking about the scary part of the dream might reinforce the nightmare and result in memorizing your nightmare. Fear and relaxations are not compatible. The more you relax, the less fear you will have. As you get better at relaxing your fear shrinks and your dreams become less traumatic.
2. Learn sleep hygiene
Keeping regular bedtimes, reducing or eliminating caffeine especially in the hours before bedtime and other efforts to improve sleep naturally are helpful. It is important to allow plenty of time for sleep.
People who stay up late and get up early gradually become sleep deprived. Lack of sleep aggravates all sorts of mental health issues. Insufficient sleep increases the possibilities that you will be suddenly awakened and will remember the “bad dreams.”
During sleep the brain keeps working on our issues, memories are consolidated and thoughts organized. We only call dreams “nightmares” if we awake during the dream and have memories of it. Better sleep can result in fewer nightmares.
3. Begin treatment of the nightmares once you are relaxed and well rested.
The process of “reframing” nightmares makes them less scary and more manageable. Reframing or reprocessing is helpful for intrusive daytime thoughts as well as for nightmares. The application of this to reducing or eliminating nightmares was described by Rhudy et al. in their 2010 article on CBT treatment for nightmares in trauma-exposed people, where they called it “ERRT” therapy. Ben Furman has also described a similar approach for use with children.
Disclaimer- Rhudy et al.’s study, like most research in the mental health area, excluded substance abusers, people with mania or psychosis and probably screened out all people with Bipolar Disorders. The sample size was also low with about twenty people per group. There is so much overlap between substance abuse, bipolar disorder and PTSD in the clients I see these studies leave out exactly the people who most need new effective treatments. That said – the ideas appear to be fully appropriate for clients with co-occurring disorders.
Here is how it works:
To reprocess or reframe nightmares do the following things:
A. Write out as full a description of the nightmare as possible.
Getting it down on paper tames the story and makes it manageable. It also allows you to go back over it and add missing details. In step C you will be rewriting it with added insight.
Remember that it is a normal process for your brain to use your dreams to make sense of your experiences. In dreams, your brain will turn the experience around and examine it from all sides. Your brain may also play out multiple alternative endings for the event. It is not the dream that is the problem; it is the connection between the dream and fear that makes this a nightmare.
If you have several versions of the dream try to write them all down.
B. Read the nightmare story aloud.
Listen for the themes in the story. What are the fear messages? I think it is helpful to be able to read this to a therapist or other support person who can keep you from being overwhelmed and can provide some insight to things you may not immediately see. Just don’t make someone listen to your nightmare that is not emotionally able to hear the story.
C. Re-script the nightmare.
What is the expected ending? What is an alternative ending? Write out the story this time with a new less scary ending. Read the new version out loud. Has seeing a new possible ending tamed the fear?
Furman described a story, not sure where it originated, in which a grandmother applied the sort of approach to her grandson’s nightmare.
The child came to grandmother scared because of a nightmare.
“Grandma, ” he said, “I had a nightmare.”
“There are no such things as nightmares,” The grandmother said “Only goodmares. All dreams should have happy endings. The problem is you keep waking up before the end. What is a good ending that could have happened?”
In this story the child then works with his grandmother to find new happy endings for these scary dreams. The result – fewer scary dreams and less fear when bad dreams occurred.
Warring – in people with PTSD who were treated with re-scripting the fear declined first, anger later and the frequency and length of nightmares were the last thing to decline.
Talk to your care provider about this process. If you try this process, see if it works. Learn to relax more. Tame your sleep. Then tame your nightmares. If you have had success in changing your nightmares ending please share your success with the rest of us.
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For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books