Nightmares are unpleasant dreams that cause high anxiety while being experienced. This is a normal phenomenon that we have all experienced; however, when they become recurrent, we can talk about nightmare disorder .
Imagination therapy is an effective type of therapy to eliminate them . In this article we will know what this technique consists of, how it is applied, the three steps that make it up and what the scientific evidence says about it. In addition, we will see what some authors think about the mechanism that explains its effectiveness.
Nightmares and Nightmare Disorder
Imagery trial therapy is a type of therapy used to treat nightmares. Nightmares are terrifying dreams that we have all experienced at some point in our lives.
They appear mainly in childhood and adolescence (to a lesser extent), and having them is not considered pathological; however, when their frequency is exaggerated, and when they cause clinically significant discomfort, it is considered a sleep disorder (nightmare disorder).
Thus, as a disorder, it is classified in the DSM-IV-TR and the DSM-5 (Diagnostic Manuals of Mental Disorders) as a sleep disorder. Nightmare disorder consists of the appearance of unpleasant and even terrifying dreams, which wake up the subject and leave him/her with a vivid memory (which fades away). All of this causes the subject to feel uneasy and/or interferes with his/her normal functioning.
Nightmares are a type of parasomnias, and they occur in the second half of sleep, in the REM phase. Parasomnias, on the other hand, are sleep disturbances that occur during waking, sleep-wake, or sleep (specifically, in REM sleep).
In nightmare disorder, once a person wakes up, he or she regains an oriented, vigilant state.
Imagination Trial Therapy: Characteristics
Imagery rehearsal therapy (IRT) is considered the therapy of choice for treating nightmare disorder, or simply nightmares , especially in childhood (although it is useful at all ages). Imagery trial therapy has been used for more than 10 years with war veterans and people who have been physically abused, all of whom have recurring nightmares.
The effectiveness of this therapy has been investigated through different studies, and these show how it is an effective therapy to reduce and even eliminate nightmares. In addition, other studies have compared the effectiveness of imaginative trial therapy with the use of venlafaxine (antidepressant; selective serotonin and noradrenaline reuptake inhibitor) or prazosin (drug used to treat hypertension), and have shown that the effectiveness of IRT and the drugs are similar.
Imaginative trial therapy aims to get the patient to re-elaborate the nightmare they have had, including a positive and pleasant ending; that is, to modify it as they wish to make it pleasant. In the end, the patient learns to “change” the content of his own nightmares , exercising control over them even while he is sleeping. But how does he manage to do this?
Let’s look at it through the four steps of imaginative trial therapy.
1. Writing the nightmare
The first step that the patient should take is to write down (and describe) the nightmare he has had ; ideally he should do this immediately after waking up, since as time goes by, it is forgotten. If this is not possible, the ideal is to select a nightmare with the therapist and write it down.
It is recommended that you do it on a piece of paper and with natural light, or artificial light but with low intensity, right next to the bed. The use of a tablet or telephone is not recommended, as the type of light these devices emit is harmful in this case, and would interfere with sleep recall.
2. Rewrite the Nightmare
The second step of imaginative trial therapy consists in reworking the nightmare , in rewriting it so that it ends up becoming a pleasant dream, or at least, with a happy ending. That is, the subject changes the nightmare to his or her liking, and describes the new version in detail. Later this new version will be discussed with the therapist.
To rewrite the nightmare, the use of imagination will be essential. This is not an easy step, as it requires practice and perseverance; the ultimate goal is for the subject to be able to include pleasant details, and to imagine it as vividly and realistically as possible.
3. Induce the intention to dream again
There are people who can have “lucid dreams”; that is, they can dream by “being aware” that they are dreaming during the same dream. This means that they can even “intervene” within the dream, or influence it.
This ability to dream lucidly, however, is an ability that few people have. That is why most subjects must train and practice to achieve it, or at least to get a similar experience.
Therefore, in the third step of the imaginative trial therapy, the subject, before falling asleep, will try to influence the fact of having the nightmare again. To do this, he will apply three steps:
3.1. Repetition of a sentence
Just before falling asleep, the subject will say to himself: “If I start having the nightmare, or when I do, I will be able to influence to have a much more pleasant sleep” . . He has to repeat that sentence as a kind of “mantra”, internalizing it in his head.
3.2. Imagine rewritten dream
In this case, the subject must imagine the pleasant dream that he rewrote through the nightmare, in all detail. This step can be repeated; the more the subject imagines the dream, the better.
The aim is for the subject to mentally review the sequence of the new images during the vigil . Ideally, they should spend between 5 and 20 minutes a day. On the other hand, it is recommended that you work with a maximum of 2 or 3 nightmares at a time.
3.3. Repeat step 1
The last part of the third step of Imagination Trial Therapy is for the subject to repeat the initial phrase (from step 1), as many times as necessary.
4. Success + Repeat process
The fourth and final step of imaginative trial therapy comes when one succeeds in replacing the nightmare with pleasant (i.e. dreaming) sleep , or when one succeeds in influencing the course of the nightmare to change it for the better. In other words, when success is achieved and the nightmare disappears.
The last step, in turn, involves repeating the previous steps as often as necessary when new nightmares arise.
On the other hand, the ideal is to test the technique for at least ten nights, to see the results obtained, the possible obstacles that appear, the resistances, improvements, etc.
Mechanism of action
Although imaginative trial therapy is considered an effective therapy, it should be further investigated, as the studies conducted are single case reports and some controlled studies .
What is controversial, however, is determining precisely the mechanism of action of the technique; that is, why is it effective? Two authors have given their opinions on this subject: Marks and Krakow.
Thus, while Marks raises three key elements in Imagination Trial Therapy, which are exposure, abreaction (relief) and mastery (learning anxiety management skills), Krakow talks about 1 essential element: the process of sleep modification (according to this author, this would be the element that would explain the effectiveness of the technique).
American Psychiatric Association (APA) (2014). DSM-5. Diagnostic and statistical manual of mental disorders. Madrid: Panamericana.
Aurora, R., Zak, R., Auerbach, et al. (2010). Good practice guide for the treatment of nightmare disorder in adults. Journal of Clinical Sleep Medicine, 6, 389-401.
Pérez, M., Fernández, J.R,; Fernández, C. and Amigo, I. (2010). Guide to effective psychological treatments I and II:. Madrid: Pirámide.