Image Rehearsal Therapy (IRT) is one of the best-suited methods for the treatment of nightmares in adults. At least this is what the 2018 position paper of the Journal of Sleep Medicine concluded.

What is IRT? Is it something you should consider for the treatment of your nightmare problems?

Below, we dissect this relatively novel treatment method. While at it, we will hopefully answer those questions and more.

  • What is IRT?
  • What therapeutic components make it up?
  • What can you expect from an IRT treatment session?
  • How does science rate the efficacy of IRT for the treatment of nightmares?
  • Are there any risks associated with IRT?

What is IRT?

Image Rehearsal Therapy is a cognitive behavioral therapy variant. Its goal is to alter the image content of a nightmare and to have nightmare sufferers rehearse this altered dream scenario. This way, when the nightmare pops up again, the brain will give it the rehearsed positive twist.

IRT’s therapeutic process is a two-pronged approach.

First, it aims to familiarize patients with the idea that their nightmares are the results of a learned sleep disorder. Once people recognize that their nightmares are sustained by habit, they become open to having them treated directly.

Nightmares are associated with insomnia. In a way, they represent yet another symptom of insomnia. As such, they can, and should, be treated as a sleep disorder.

Secondly, IRT familiarizes patients with imagery techniques. Eventually, it uses these techniques to alter undesired dream content, conditioning the mind to directly address disturbing dream imagery. This stage of the treatment identifies nightmares as symptoms of imagery system damage.

What are the Therapeutic Components of IRT?

A typical IRT treatment consists of four sessions, each of them two-hours long. The first two such sessions focus on the first stage of the therapeutic process. The last two focus on the second stage.

During the first session, the therapist sows the seeds of therapeutic credibility and builds rapport with the patients. Given the somewhat novel nature of the therapy, patient skepticism can be a problem at this stage.

The first therapeutic step is linking nightmares to poor sleep quality. In this regard, the therapist touches on several factors, such as:

  • Disrupted sleep due to nightmare-induced awakenings.
  • Pre-sleep anxiety.
  • Sleep avoidance after a nightmare-induced awakening.
  • Nightmare-induced emotions.
  • The wakeful reliving of nightmare-induced emotions.

The second step links the treatment of nightmares to improving sleep quality.

  • Therapy will result in the elimination of pre-sleep anxiety.
  • Reduction of fragmented sleep.
  • Better sleep consolidation.
  • More restful sleep.

It is worth noting that during the first session, patients will NOT have to detail their past traumatic experiences and nightmares. This stage of the treatment is dedicated to building credibility, linking insomnia to nightmares and addressing the transition of the nightmare disorder from the acute to the chronic stage. The therapist will also discuss the psychological benefits of nightmares.

During the second session of the treatment, the therapist discusses nightmare persistence. The first imagery-focused exercises enter the picture. The analysis focuses on the following concepts:

  • Why do nightmares persist after traumatic exposure? The learned/habit-based nature of nightmares is introduced to patients.
  • When treatment takes direct aim at nightmares, what happens with the symptoms? (They subside surprisingly quickly.)
  • The therapist asks participants to define their proportion of trauma-based and habit-based nightmares.
  • The specialist introduces the first concepts of imagery.
  • Patients practice pleasant imagery. The therapist addresses eventual difficulties linked to using imagery.

The third session focuses entirely on imagery. More precisely, it introduces the role of imagery in eliciting change.

  • The therapist first explains the role of imagery in the change process. Patients are asked to reflect on the processes involving imagery that preceded some previous changes in their lives.
  • Patients perform imagery exercises. For example, they imagine re-modeling a room in their home.
  • Once he/she cements imagery as a vehicle of change, the therapist focuses on patients’ nightmare identities.
  • The therapist concludes that nightmares result from learned behavior. Likewise, one’s nightmare identity is learned.
  • Imagery is used to change nightmare identities.

The fourth and final session marks the first time patients attempt to address their nightmares directly. At this point, therapy subjects should be aware that they can change their nightmares the way they wish.

  • Patients select a less intense nightmare first. It is important from a therapeutic perspective to adopt this gradual approach. Having chosen such a nightmare, the patient then changes it. According to Barry Krakow and Antonio Zadra, choosing a daunting nightmare initially may throw the patient off the treatment course, due to its difficulty.
  • Next, patients change their chosen nightmare through imagery. All they have to do is to imagine a different course for their nightmare. There is no clear-cut technique in this regard. Nightmares should obviously be given a positive imaginary twist. Patients change their dreams in different ways. Some resume to tweaking some details, while others change the entire storyline.
  • Rehearsal is about the new/changed dream only. It does not involve the original nightmare in any form. At this stage of the treatment, patients should be able to handle potentially negative images that may arise during the imaging/rehearsal exercise.

How Does Science Rate the Efficacy of IRT for Nightmares?

Scores of researchers have proven beyond doubt that IRT is highly efficacious in the treatment of idiopathic as well as PTSD-related nightmares.

In their 2004 study, titled Increased Mastery Elements Associated With Imagery Rehearsal Treatment for Nightmares in Sexual Assault Survivors With PTSD, Germain A., Krakow B., Zadra A., and others, have concluded that IRT does not just significantly reduce nightmare frequency and intensity, it also achieves its effects with minimal exposure.

In a 2003 study, Germain A. and Nielsen T. investigated the impact of IRT on nightmare frequency and psychological distress. The results of the study found the method efficacious for the reduction of nightmare frequency as well as psychological distress.

In a 1987 literature review, Halliday G. took a close look at direct psychological therapies for nightmares. Among several other methods, “storyline alteration” has been found to be an effective way of treating nightmares.

Does IRT Carry Any Risks?

As mentioned, IRT involves minimal exposure, and therefore it is an extremely safe nightmare treatment method. At no point during the treatment will the therapist ask you to relive a trauma or a nightmare. That said, imagery exercises may unearth negative results in some patients.

In this regard, I have to note that:

  • For patients with PTSD, negative imagery carries increased risks. Such patients should stop the exercises as soon as they conjure up such images.
  • The activation of the imagery system should take a gradual course. Patients such ease into the imaging flow, even if they show affinity and curiosity towards the process.
  • It is important to teach patients how to handle negative imagery before more consistent exercises commence.
  • Patients should bear in mind that some of the unpleasant imagery they may experience stems from learned behaviors, rather than stress-triggered psychological processes.

Bottom Line

While personally I prefer to prescribe to my clients a more powerful technique which consists of altering the nightmare from inside the dreamworld by becoming lucid (see: Lucid Dreaming Therapy), for some people lucid dreaming doesn’t come easily. For them, I would absolutely recommend image rehearsal therapy.