Wednesday, April 29, 2009

For Therapists: Working with Nightmares

A nightmare is any dream that is so intense, so frightening, that it disrupts your sleep and leaves you in a heightened state of psychological and physiological arousal and discomfort.

*Nightmares are typically more common in children. One out of every four children experiences at least one nightmare a week; up to 30% of adults experience one nightmare a month and 6% weekly. Recurrent nightmares often begin in childhood and often portray the dreamer as being chased or threatened by unknown people, monsters, or animals.

*What contributes to having a nightmare? Oftentimes narcotics, medication, and withdrawal from REM-suppressing drugs, including opioid analgesics can cause nightmares. Some researchers have also identified certain personality traits common to people who experience chronic nightmares including thin boundaries, creativity, sensitivity, defenselessness, and an openness to experience. Nightmares are also more common during periods of unusual stress, at the onset of medical problems such as temporal lobe epilepsy or psychiatric disturbances, such as depression or schizophrenia-spectrum disorders. Nightmares also increase after a traumatic event in waking life.

*What affect do nightmares have on waking life? As a result of a nightmare or recurring nightmares, people often experience disorientation, confusion, anxiety, a fear of sleep, and general agitation for hours, days, or even weeks later. Research has also reported a co-occurrence of insomnia, chronic fatigue, compromised immune function, impaired psychosocial and interpersonal function, depression, and occasionally substance abuse in adults who have frequent nightmares.

*Are nightmares REM-related? Nightmares tend to occur late in the sleep cycle (closer to morning); however, nightmares have been reported during non-REM sleep across the entire sleep cycle, particularly for nightmares that occur after traumatic waking life experiences.

*What about nightmares as a result of a trauma? Although post-traumatic nightmares vary considerably with regard to their duration, frequency, and the exactness with which the traumatic event is re-enacted, they tend to gradually lose their intensity and similarity to the traumatic event as the trauma survivor navigates through the process of recovery.

When working with nightmares in treatment, it is important to keep a slow pace. A client may feel resistant to exploring a nightmare because it can cause emotional distress. It is important to recognize that a client may resist talking about nightmares in order to protect the therapist from being traumatized by the material, or out of fear that the therapist cannot manage the intensity of the content, or cannot manage the client’s emotional reaction to it.

As a result, it is important for the therapeutic relationship to include a sense of safety and trust. A discussion about confidentiality and the limits of confidentiality is usually done early in treatment; the therapist also needs to be sure that the client has access to an effective social network. Additionally, the therapist should have an adequate knowledge of the client's personal history. In the early sessions, the therapist can gather information about the onset of nightmares, nightmare frequency, nightmare intensity, presence of sleep disorders, and treatments sought for nightmares. Then the therapist can explain the benefits, the process, and the therapeutic goals of nightmare work. It would be important to tell the client that as dream work begins, it is normal to experience an exacerbation of nightmare frequency or severity. Follow up on this regularly. And check in often with the client about any questions or concerns he or she may have.

The work done on one nightmare can be spread out over three sessions. Begin by having the client tell the dream in the present tense, using a detailed description. It is helpful if the client can re-experience the nightmare, not with the goal of catharsis, but with the goal of exploring the emotional and cognitive content in a safe, contained setting. As the therapist, help the client maintain a sense of control through pacing, checking in with them on their anxiety level, and using relaxation techniques and normalization as appropriate.

Explore the client's affective response to the dream as a whole. The therapist can use a gestalt technique such as “staying with” a particular emotion or the empty-chair dialogue exercise to help clients identify, clarify, and confront their thoughts and feelings. Look at the language the client uses to explore the dream.

The client can choose from five to seven images to examine more closely. These images do not need to be in sequence. Highly arousing images in nightmares could be too overwhelming to explore. Start with less arousing images. The client will feel in control and the therapist will be able to assess readiness for more difficult content. Encourage the client to describe the images, re-experience the feelings associated with each image, associate to the images, and connect with waking life triggers.

When a client becomes anxious, help them manage their anxiety with whatever tools you use as a therapist. Tension and anxiety can be reduced through progressive muscle relaxation, deep breathing, visualization, grounding exercises to focus on the present, or rating their anxiety on a scale of 0-11 (0 = neutral feelings/no anxiety, 11 = highest level of anxiety possible). When the client feels ready, they can resume dreamwork.

When the client has completed the exploration stage by talking through the five or seven images, the therapist can retell the client the nightmare, inserting the client’s associations, descriptions, and waking life links throughout as appropriate.

Now move the client on to insight. Begin by getting a sense of what the client understands about the nightmare. Then help the client move further into new insight and understanding.

Finally, if you are of a behavioral bent, you can help the client move from insight into action. This is a difficult stage for nightmare sufferers. It often means confronting intense fears and conflicts that the client works hard to avoid or has failed to overcome. The therapist provides support, guidance, and structure to help the client stay focused on the present, address resistance when encountered, and work through the process of change in a manner that is safe and manageable. The therapist can ask the client how he might change his behavior or role in the nightmare given his new understanding of it. Then explore with the client how to translate these changes in fantasy to actual changes in waking life. The therapist can suggest role playing to practice the action plan and then imagery rehearsal to develop and reinforce positive imagery around the task. Before ending the action stage of dreamwork, the therapist should ask the client to summarize his action plan and explore with him any concerns he may have with implementing the plan (such as perceived barriers, handling failure or setbacks, gauging success).

Exploring the nightmare in more than one session is helpful in that continued re-exposure in a safe, controlled environment further develops and refines the client’s understanding of the nightmare and any beneficial action that may result from this new understanding. Subsequent sessions could also incorporate a different approach for insight into the dream, depending upon the flow of the discussion and the material acquired through exploration. Dreams often have many layers of meaning.

source: Hill, Clara (2003). Dreamwork in Therapy.

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