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Dream engineers work on promising ways to improve nightmare treatment

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A group of dream researchers I met with this past month are focused on using technology and engineering to tackle big questions about dreams. February’s session was focused on improving treatment for nightmares. Consistent themes were: adding sensory triggers during dreaming to augment existing treatments; and the clear need for effective nightmare treatments to be implemented more widely.

 

Presenter Westley Youngren noted that current methods have variable effectiveness. The main nightmare prescription medication, Prasozin, did no better than placebo in a recent study. Imagery rescripting methods, the main psychptherapeutic intervention, have also shown varying levels of efficacy. “There’s room for improvement, so there’s room to take new and cutting edge science coming from the sleep and dreaming world and use this to improve upon current treatment options,” said Youngren.

 

As a starting point, Youngren is studying dream efficacy – which is the ability to have an impact on the content of your dreams. In particular, he is interested in how various dream intervention devices that you wear to track and send signals during sleep, can impact dream efficacy. Ultimately this information can lead to developing the best approach to change the course of nightmares from right inside the dream.

 

The Dream Engineering series is led by Dr. Michelle Carr, recently appointed assistant research professor at the University of Montreal and the Center for Advanced Research in Sleep Medicine. She plans to continue building this enthusiastic collaborative group focused on dream engineering. Her research interests are in dream function, how dreams impact waking life, and how these functions can be disrupted by nightmares. For example, she has researched ‘targeted lucidity’ using light and sound cues to trigger waking dream awareness, which can be used to treat nightmares.

 

Suicide researcher Dr. Michael Nadorff spoke about the alarming link between nightmares and suicide. He quoted an important study by Sjostrom and colleagues (2009) that found a 400% increase in suicide risk for those with frequent nightmares. The study followed 165 inpatients hospitalized for suicide attempt for two years, and found that persistent nightmare predicted suicide even after controlling for depression, anxiety, posttraumatic stress disorder and substance use. Nadorff’s own research supports this finding of nightmares as a independent risk factor for suicide, and he suggests more can be done about this:

 

“Time and time again in the literature, we’re seeing something unique about nightmares and suicide. We know that the strongest predictor of suicide is a past suicide attempt. So we did a study that looked at individuals who had one attempt in the past versus multiple suicide attempts to see what factors differentiate those groups. What was interesting is a lot of the main risk factors you know of did not significantly predict multiple attempts: not depression, anxiety or PTSD. Nightmares were the only factor in our study that actually differentiated repeat risk, and it was both current symptoms and chronicity independently. There’s something about having nightmares that puts you at greater risk of future suicide attempts. So there’s tremendous clinical need for these interventions.”

 

Lampros Perogamvros presented his research into using targeted memory activation (TMR) to increase the effectiveness of imagery rehearsal therapy (IRT) for nightmares. During the ‘rescripting’ phase of IRT, the new dream ending was paired with the sound of a piano chord, and this same sound was played during REM sleep. Of the 36 participants, half received the TMR/sound treatment. All participants reported fewer nightmares, but those who used the sound protocol had more positive dreams as well as significantly fewer nightmares than the control group. The mechanism did not seem to reduce fear within the dreams, but rather, to increase dreams with a positive valence. This unexpected result nevertheless shows that there are effective ways to augment existing nightmare therapies. There will surely be more to come from this engaged group of dream engineers.

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Experiential Dreamwork: Adding depth, creativity and transformation of trauma memory for you and your clients

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Over time, dreams appear to help take the emotional charge out of challenging memories while enabling us to retain the information we need to make more adaptive decisions in the future. Engaging with dreams can augment and strengthen this process.

By Dr. Leslie Ellis

Paying attention to dreams adds richness, creativity and depth to inner process. Bringing experiential dreamwork into clinical practice also increases the likelihood that clients will experience deep and lasting change. In my recently-published book, A Clinician’s Guide to Dream Therapy (Routledge, 2020), I offer many reasons for therapists to engage in dreamwork, both for themselves, and with clients. I close the book with a chapter on how neuroscience and dreamwork can combine to bring about transformation of core emotional patterns and beliefs. In this article, I offer a summary of these highlights from my book.

 

Why work with dreams?

“Clinicians who do not pay attention to their clients’ dreams are missing an opportunity to add a compelling dimension of depth, meaning and emotional authenticity to the therapy process. Because dreams often speak the language of metaphor, even the most seemingly-mundane content may carry important meaning that is outside of the dreamer’s immediate awareness. For example, a client who regularly brings dreams to therapy told me in one session that she had lots of dreams the previous night, but nothing important. Her dogs were in the dream, doing what they always do: the younger one pestering the older one who was, in the dream, getting to the point where she simply couldn’t take it anymore and was ready to snap. While acknowledging the dream snippet was literally true, the simple query: “Is there anything in your life like that, anything that you are completely fed up with?” opened up a whole avenue of process for her that was aptly represented by the dogs and may well have been left unexplored had she not mentioned her dream.

 

In addition to turning our attention to deeper matters, the benefits of working with dreams in clinical practice include the fact that dreams are creative and engage clients in the therapy process. They point to our most salient emotional concerns. They bypass our internal editing process and normal defenses, and so are unflinchingly honest representations of our life situation. Dreams can bring a new and wider perspective on a situation that seems otherwise stuck. They provide diagnostic information and can be indicators of clinical progress. They help to regulate our emotions, and working directly with the feelings dreams engender may strengthen this positive effect. They can be a safe pathway to working with trauma. The ‘big’ dreams we occasionally experience can literally change our lives, and dream therapy can facilitate and integrate this transformation.

 

Much of what we know about how clinicians use dreams in their practice is captured in a handful of studies that were reviewed by Pesant and Zadra (2004) with the goal of making clinicians aware that integrating dream work into their practice is both beneficial and accessible. The researchers found that while most therapists do work with dreams at least occasionally in their practice, the majority are not comfortable doing so because they feel they lack expertise or the necessary specialized training. In fact, it is most often the clients, not the therapists, who initiate dream work. The review also found evidence that dream work helps increase clients’ self-knowledge and insight, and increases their commitment to therapy, which can be a predictor of good therapy outcomes” (from chapter 1, A Clinician’s Guide to Dream Therapy).

 

Dreamwork informed by neuroscience can lead to transformation

We will now skip ahead to the final chapter which brings much of the preceding information together. I map a process that touches on how dreams are implicated in the updating of our emotional memories. The following is an abbreviated version of the last chapter: Transformation: Applying neuroscience to dreamwork.

 

“It used to be thought that emotional memories were not malleable, but the discovery of the processes behind emotional memory reconsolidation (Lane et al., 2015) has changed this view. Current evidence suggests the brain is more resilient and capable of changing and healing than previously thought, even later in life. This is a cause for optimism because now that we know something about the specific mechanisms of change, we can attempt to engineer our therapy processes to engender such changes. The beauty of this kind of change, which can take place in basic neural structures (at the synaptic level), is that once it has taken root, the test of success is that clients maintain the changed behavior automatically and without effort. This is not the white-knuckling kind of change that reverts back to its former patterns under stress.

 

Implicit emotional patterns are malleable, and can permanently transform into more up-to-date responses, but only under the right circumstances. It used to be thought that long-term emotional memory was indelible because it was stored in synapses, in the basic structures of the brain. But Lee and colleagues (2004) have shown that if certain conditions are met, the synapses will destabilize, making revision of fear memory possible without reinforcing the original memory. According to Ecker, Ticic and Hulley (2012), the keys to unlocking the emotional brain involve clear, repeatable steps that involve juxtaposing a deeply-felt experience of an outdated emotional belief with something that feels true in current life, but opposite. This creates instability in the memory, and if the new experience is reinforced in a timely way, it will not just cover over or compete with the old information, but will actually replace it. Ecker and colleagues state that the resulting change will be transformational, rather than incremental. In my experience, this can be the case, but when beliefs arose in different contexts, transformation may take place over time, with repetitive experience of how the new experience contradicts the older paradigm.

 

Do not treat the trauma itself, but the beliefs that arise from it

This research highlights something important to keep in mind when working with trauma. The traumatic events themselves are not the important focus. The process, and an open curiosity should be directed to the beliefs that arose out of the traumatic events with the understanding that fear generalizes. For example, people who suffered from chronic neglect in childhood often develop the belief that no one is ever there for them. Feeling deeply into the experience of having even one person consistently show up for them has the potential to shift this long-standing emotional pattern. This is why falling in love can be transformational. Implicit emotional beliefs are not generic, however, but quite specific. They must be experienced in the body rather than speculated about with the mind for the change process to initiate.

 

Such beliefs and their opposites are often referred to in dreams. Jung was the first to notice this pattern. He found it so pervasive that he developed his theory of dreams as compensation around this idea. Although many early theories about dreams have been successfully challenged, this one persists and is incorporated into many current theories that suggest dreams bring new information and have the potential to transform our long-held emotional beliefs based on current experience. Therefore, dream material can be a rich source of experiential information to use as a base for facilitating memory reconsolidation.

 

Doing what dreams do, only better

This section describes how we can take a dream and by focusing on it, assist in the very processes that dreams are implicated in – those of emotional memory reconsolidation and emotional regulation. Over time, dreams appear to help take the emotional charge out of challenging memories while enabling us to retain the information we need to make more adaptive decisions in the future. Dreamwork can augment and strengthen this process. And it can kick-start a ‘failed’ dreaming process that is not working as it should, as is the case with recurrent nightmares of those suffering from posttraumatic stress disorder (PTSD).

 

One of the challenges of trying to engender emotional memory reconsolidation is that it can take quite a bit of detective work to uncover an outdated emotional belief that was formed implicitly. Ideas about the nature of the world are often formed in childhood based on experiences from one’s family of origin, and early beliefs are rarely explicit or called into question. Having no other frame of reference as very young children, we see our environment as simply how the world works, and the beliefs we pick up are a way of adapting to the emotional and relational world we found ourselves in. Dreams, however, can bring our emotional beliefs to life as metaphorical images we experience directly. They often represent novel information that contradicts what we believe. Such images are the keys that can unlock the process of emotional memory reconsolidation, updating and transforming how we respond to life situations in light of current experience.

 

Those who consistently work with dreams as part of their practice of psychotherapy already have an intuitive understanding of how to work with dreams to bring about therapeutic change. Most invite their clients into a deeply experiential sense of the dream, a critical ingredient in the process. Dreams often have within them contrary elements that can be juxtaposed. Inviting the dreamer to deliberately hold this ‘tension of the opposites’ (Jung) can bring about deep and durable emotional shifts.

 

In my book’s final chapter, I am suggesting that armed with a basic understanding of the role of dreaming in emotional memory consolidation, we may be able to explore the dreams that clients bring to therapy in a way that facilitates or strengthens the helpful processes that dreams are already a part of. Well-considered current theories suggest that: dreams are implicated in the process of reducing the emotional charge of memories that have current relevance; and dreams play a part in updating our store of memories to include current experience, better preparing us for what’s next. This could also serve as a definition of what happens in psychotherapy. Not just the dreams themselves, but the dreamwork process within therapy can facilitate these emotional and memory updating processes. In addition, nightmare treatment research has shown that by using what we know about dreams in specific and thoughtful ways, we can repair sleep-dream-memory processes that are not working well, helping healthy dreaming to resume.

Clinical examples of transformational dreamwork

What I have noticed about the process of memory reconsolidation is that theories of psychotherapy incorporated its basic elements well before the neuroscience underlying the process was discovered. The trend in dreamwork toward greater experiential practices is an example of how therapists intuit and/or learn by experience to use methods that engender change. In addition, Jung’s notion that dreams are compensatory, and Gendlin’s bias control are two ways dreamwork brings about an experiential juxtaposition that can cause significant shifts in the dreamer’s store of emotional memory.

 

An example of memory reconsolidation at work is shown in the dreamwork with the Grateful Dead dream earlier in this book. Initially, the dreamer is terrified of being shot by ‘Jack’, the man who in waking life had been abusive and was now aware of where the dreamer worked. In the dreamwork, this fear was juxtaposed by the feelings of safety I encouraged her to sink into very deeply. There were at least two safe places in the dream to draw from: memories of her first love, and also being with a group of like-minded people on the bus who prevent Jack from harming her. In a later part of the session, I ask the dreamer to ‘be’ Jack for a minute, another form of juxtaposition; she feels how hollow and sick he is, before we move on to the part of the dream where she is safe on the bus.

 

There is a palpable release of tension in the course of working with the dream, and this is sustained, which is the hallmark of a successful memory reconsolidation process. The dreamer reported that prior to the dreamwork, she felt very anxious in general, and especially going to work. After the dreamwork, the fear was no longer present. She said, “I’m not holding the charge anymore.” She could walk into work without her usual worried pausing at the threshold, and this was not a conscious, but an effortless, automatic action reflective of a structural change in the nature of her fear memories. Interestingly, in her subsequent dream, she confronts Jack and he apologizes, which is further evidence of change. I believe such dream changes are significant and authentic reflections of clinical change because they happen without conscious volition.  The dreamwork also shifted the way the dreamer holds the memories about Jack, with more of a focus on her friends coming to her rescue and her desire to cultivate community in her life.

 

The ‘new was’

In the preceding example, the client arrives at a new vantage point. From there, she views the past differently, but also, paradoxically, with a sense that it has always been that way.  Gendlin (1984), called this the “new was.” He viewed feelings, thinking, actions and words all primarily as lived experience in the body, and each bodily event as implying what comes next. He called this ‘carrying forward’ and said, “In therapy we change not into something else, but into more truly ourselves. Therapeutic change is into what that person really ‘was’ all along… it is a second past, read retroactively from now. It is a new ‘was’ made from now.”  From this new was, steps come that change one’s conception of the past entirely. The change is not just a current one, but a shift that ripples through our entire store of memory, revising many things accordingly.

 

There is room here to think about state-dependent memory, something I encounter frequently in working as a psychotherapist. To play with the above example, when the client feels afraid, the memories of Jack feel much more ominous and she recalls the worst ones. When she is less afraid, she may recall better times, such as her earlier relationship with her first love.  This fear bias colors her perception of the world in general, and of relationships specifically. I believe that the elements of this dream were particularly salient and powerful tools for engendering lasting change in her sense of relational safety. It can be a challenge in psychotherapy to create deeply-felt juxtapositions necessary to revise emotional memory, but dreams provide ready-made and highly relevant material for this powerful transformation process.

 

 

Dr. Leslie Ellis is an author, teacher, researcher and therapist with an abiding interest in inner life. She teaches therapists how to work with embodied experience, trauma and dreams, and offers on-line courses in dreamwork and focusing. She has a PhD in Clinical Psychology with a somatic specialization. Shen has conducted award-winning research in treating nightmares of refugees using embodied dreamwork techniques. For more information, go to https://www.drleslieellis.com or contact her at leslie@drleslieellis.com.

 

References

Ecker, B., Ticic, R. & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York: Routledge.

Ellis, L. (2019). A Clinician’s Guide to Dream Therapy: Implementing Simple and Effective Dreamwork. New York & London: Routledge.

Gendlin, E. T. (1984). The client’s client: The edge of awareness. In R. L. Levant & J. M. Shlien (Eds.), Client-centered therapy and the person-centered approach. New directions in theory, research and practice, pp. 76-107. New York: Praeger.

Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. (2015). Memory reconsolidation, emotional arousal, and the process of change in psychotherapy. Behavioral and Brain Sciences, 38.

Lee, J. L., Everitt, B. J., & Thomas, K. L. (2004). Independent cellular processes for hippocampal memory consolidation and reconsolidation. Science, 304, 839-843.

Pesant, N. & Zadra, A. (2004). Working with dreams in therapy: What do we know and what should we do? Clinical Psychology Review, 24, 489–512.

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There is no hurry

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Speed is the enemy of depth

This January, I was in stormy Santa Barbara at a 3-day dream tending retreat at Pacifica Graduate Institute. Midday of the first class, we were informed of flood and landslide warnings right in our location! So we hastily gathered our things and dashed to our cars in the pouring rain, navigating deepening water on the roads and with a mild sense of panic. But despite all the commotion outside, the next couple of days ended up being more focused on our inner worlds. Holed up in Oxnard at a friend’s condo safely away from the flood zone, it turned out to be a perfect venue for turning our attention inward.

 

My grandmother’s wisdom

In dream tending, we are invited to use our dreams as starting points for imaginal journeys. In my inner travels, my grandma Danchuk came along with me into the land of imagination, as she often does. She is my mom’s mom, and I remember her for her warm chuckle and the endless activity of her hands, always crocheting, cooking, or tending the garden.

In the dreamscape, I am itching to get going, to set off on an adventure. But she stops me and says, ‘There is no hurry.’ She is, of course, tending a garden in this imaginal landscape. Through this, she illustrates for me the importance of patience. First we prepare the soil, and plant the seeds. And then we wait. When the plants sprout, we weed, water and tend. But again, we wait. There are bouts of activity, but mostly, gardening is an act of patience. This is not my strong suit, but I sit next to my grandma on a lounge chair and look out at the water. It is wonderful to simply slow down. My body likes it. In our sped-up and distracted culture, I believe we all need more of this.

 

Speed is the enemy of depth

Coincidentally, I have been reading a book called Stolen Focus – in which Johann Hari explores the multiple causes for our shrinking attention spans. He says it’s not our fault, and nor are social media and the internet the sole causes (although they do contribute greatly to the problem). Hari found that our collective attention span has been shrinking for more than 100 years because of the massive expansion of information we are bombarded with.

Quoting Danish math professor Sune Lehmann, Hari notes that this information explosion comes at a great cost. “What we are sacrificing is depth in all sorts of dimensions… Depth takes time. And depth takes reflection.” Speed is the enemy of depth. When we are exposed to more information than we can actually process, we experience a “rapid exhaustion of attenion resources.”

 

Mind-wandering is essential for creativity

A huge casualty of the information explosion is down-time for our minds. When we simply allow our minds to wander, we make creative new connections. Mind-wandering, day-dreaming and night dreaming are all on the opposite end of the continuum from focused, goal-oriented attention. This is not a waste of time, but actually improves our ability to think and focus.

Hari interviewed McGill neuroscientist Nathan Spreng to find out more. He found that “the more you let your mind wander, the better you are at having organized personal goals, being creative and making patient, long-term decisions.” Hardly the enemy of productivity, freeing your mind does three things: it enables you to make better sense of your life, make creative new connections, and engage in ‘mental time-travel’ that better prepares you for the future.

Interestingly, this imaginal travel is often what happens in dreaming. We are exploring a wide range of possibilities, and freeing ourselves from too narrow a focus. When I go back to the imaginal lounge chairs with my grandma Danchuk, I find another wonderful benefit. This relaxed approach feels better in my body, and I feel able to make warm and easy interpersonal connection that seems to translate from dream to waking life.

In the Oxnard condo, there were three of us thrown into close quarters with the assignment to engage in imaginal travels and to tend to each other’s dreams. This open, playful space brought us into deep connection, into matters of the heart and soul in ways that simply would not have happened if we had been in a task-oriented rush. I am taking my grandma’s words to heart: there is no hurry.

 

References

Stolen focus, Why you can’t pay attention and how to think deeply again (2022) by Johann Hari. New York, Penguin Random House

(Interestingly, Hari dedicates this book to his grandmothers.)

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Nightmares exacerbate mental illness, but treatment helps

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In clinical settings, nightmares are rarely inquired about, and even less often treated directly. Evidence that this needs to change is mounting. On a more positive note, nightmare treatment research continues to advance – and a new method shows that adding sensory triggers can strengthen treatment effects.

Review finds nightmares may contribute broadly to mental illness

A recent review by Sheaves (2022) found that nightmares may contribute to the development of psychiatric illness rather than being merely a symptom. The paper concludes that nightmare treatment may be an avenue for reducing threat-based disorders in particular.

Thirty-five studies were assessed overall. Although most were not designed to test the effectiveness of nightmare treatment, the researchers were able to note moderate reductions in PTSD and depression post treatment, plus some reduction in anxiety and paranoia following direct treatment of nightmares. As well, while nightmares are known to increase suicide risk, two studies suggest nightmare treatment mitigates this risk.

The study has an interesting focus on network approaches to psychopathology — an interest in symptoms that account for comorbid diagnoses. For example, sleep disruption can lead to a variety of mental illnesses and thus is identified as a clinical priority.

Three Ways Nightmares Worsen Mental Health

The authors suggest nightmares generate anxiety and subsequent hyperarousal that may lead to more nightmares, a feedback loop that warrants greater clinical attention. Nightmares can also exacerbate negative mood due to their distressing content. And via yet another avenue, sleep disruption, nightmares can contribute to a range of mental health issues. While nightmares are typically associated with PTSD, half of patients with psychosis or dissociative disorders and a third of those with mood disorders also experience problematic nightmares.

This research adds to the growing base of evidence for the need to treat nightmares. The authors are suggesting here that nightmares may not be an isolated symptom, but a more of a global one, and also a causal factor in the exacerbation of many forms of mental illness. While it is difficult to tease apart what is causal and what is symptomatic, it’s clear that once nightmares become chronic, they tend to make matters worse in at least three ways: by creating anxiety that generates more nightmares, by disrupting sleep and the myriad repercussions from that, and also by adversely affecting mood, especially if the dreamer dwells on the negative content.

Nightmare treatments: Education, rescripting and now, music!

Nightmare treatment can also work along several avenues. Most treatments include some relaxation and educational components that can help assuage anxiety generated by nightmares. Sometimes simple things like letting dreamers know dream content is not literal and is often an intensified image of a situation that needs attention can bring a helpful shift in perspective. For example, dreaming of killing a parent who is angry might signify an empowered response, reflecting a desire to effectively stop the aggression. It does not indicate murderous intent!

Understanding metaphoric nature of dreams brings perspective

In my extensive work with nightmares, I see two main avenues of intervention. The first is to address the activation – in terms of the nervous system, to dissipate the sympathetic charge. Working with the dream material and making sense of it in terms of metaphor often brings a new perspective. If needed, offering information about the nature of dreaming itself often helps those whose dreams are filled with gruesome or horrific content to see that this is not reflective of their character or personality, but truly just the nature of dreaming during turbulent emotional times.

Once the dream feels more approachable, I work with the dreamer to find ways to dream it forward, first by finding allies or resources to draw upon, ideally from within the dream itself. Bolstered, the dreamers typically imagine a different way forward, one that feels better in their bodies. Often, elements of these more empowered dream stories find their way into subsequent dreams, rendering them less nightmarish. Often even recurrent nightmares change, and sometimes they simply stop.

Sound added to nightmare treatment a promising new avenue

Technological advances suggest that it is quite possible to intervene in a bad dream and shift its trajectory – from the outside as well as the inside. For example, a recent study showed that pairing a revised dream sequence with a specific sound (a piano chord), and then playing the sound every 10 seconds during the dream-rich REM phase of sleep, would help them recall the new and improved version of the dream. This worked!

Perogamvros and colleagues (2022) tried it on half of a 36-person sample. All were treated for nightmares for two weeks using Imagery Rehearsal Therapy and half had the sound added. While all experienced a reduction in nightmares, those with the addition of the piano music reported fewer nightmares and more positive dreams than the control group, and these significant shifts were still apparent three months later.

The researchers noted that it was not the sound itself, but the memory trigger that accounts for the difference. Other sounds, or smells may also work to remind the dreamer of the positive shifts they created during dream treatment. This is called ‘targeted memory activation’ (TMR), a method that has been shown to enhance memory consolidation during sleep.

 

For more on how to treat nightmares, we have a full-length course and a lecture on nightmares and the nervous system. Or check out my web site for many other posts on this topic.

 

Schwartz, S., Clerget, A., & Perogamvros, L. (2022). Enhancing imagery rehearsal therapy for nightmares with targeted memory reactivation. Current Biology, 32(22), 4808-4816.

Sheaves, B., Rek, S., & Freeman, D. (2022). Nightmares and psychiatric symptoms: A systematic review of longitudinal, experimental, and clinical trial studies. Clinical Psychology Review, 102241.

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Dream changes help clinicians predict suicidal behaviors

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There is a well-established link between frequent nightmares and a greater risk of suicide, but until now, there has been no sense of specifically what to watch for in a client’s dream life to signal that their risk is escalating. However, a group of researchers has just published an article on how dreams change prior to suicide attempts.

I have long been suggesting that clinicians ask about nightmares and offer treatment if warranted. This recent study underscores the importance of asking about dreams – and offers some clarity about specific ways that nightmares escalate prior to a suicide attempt.

The naturalistic study collected dream information from 40 patients that were hospitalized for suicidal crisis, and found that 80 percent of them had experienced changes in their dream lives prior to this crisis. Two-thirds experienced bad dreams, half had nightmares and 22 percent had dreams about suicide.

The researchers also noted a progression in the way dreams changed prior to the suicidal crisis, with bad dreams appearing 4 months’ prior, nightmares 3 months’ prior and suicidal scenarios 1.5 months’ prior. They concluded: “Dream alterations and their progression can be readily assessed and may help to better identify prodromal signs of suicidal behaviors.”

The researchers studied the differences in those whose dream lives changes prior to their suicidal crisis versus those whose dreams stayed much the same, and found that those with altered dreaming had more of a family history of insomnia. Virtually all had symptoms of depression and altered sleep quality prior to their hospitalization.

The bottom line is that when you ask clients about their dream lives, you can also be alert to any changes. An increase in bad dreams that escalates to more frequent nightmares is an important change that may predict a suicidal crisis. Content of the dreams might provide some clues as well, though they are not going to dream about suicide specifically in most cases.

The other important consideration in your treatment of those who dream and sleep disturbance is escalating is that you can treat these as symptoms, not just as warning signs, and you may be able help them course-correct through direct attention to their nightmares. In other words, dream changes are not just diagnostic, but also avenues for treatment that may reduce suicide risk.

For more about what you can do to treat nightmares, I am offering a time-limited nightmare treatment course bundle, an in-depth online training for clinicians which includes a workshop on nightmares and the nervous system. You can check it out here.

References

Geoffroy, P., Borand, R., Ambar Akkaoui, M., Yung, S., Atoui, Y., Fontenoy, E., Maruani, J., & Lejoyeux, M. (2022). Bad Dreams and Nightmares Preceding Suicidal Behaviors.. The Journal of clinical psychiatry, 84(1), 1

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Focusing and Nature: Restoring connection within and without

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In focusing with dreams, I usually begin by facilitating a search for helpful elements. One of the most consistently supportive places comes from the natural world: trees, beautiful landscapes, animals, ocean… all of these images seem to call us back into a sense of connection we knew about instinctively as children, but may have lost along the way

“I deeply believe that we are all connected,” says dean diamond, a focusing coordinator-in-training who is offering a nature-based certification program beginning in March. Dean is a Nature Guided Focusing Oriented Therapist and Sandplay Therapy Intern who I have the privilege of mentoring as he develops his own focusing program. He said he has found that focusing allows both therapist and client to reconnect with our innate sense of connectedness to the natural world. When this happens, we become deeply resourced, he says, because we are re connecting with source.

I am reminded of the Mary Oliver poem, Wild Geese, which speaks to her deep connection with the natural world, and how universal this possibility is. Here is an excerpt:

You do not have to be good

You do not have to walk on your knees

for a hundred miles through the desert repenting.

You only have to let the soft animal of your body

love what it loves…

Whoever you are, no matter how lonely,

The world offers itself to your imagination,

calls to you like the wild geese, harsh and exciting –

over and over announcing your place

in the family of things.

Dean is offering his two-year program in person on his retreat property in the Cowichan Valley on Vancouver Island, British Columbia to a small group of students. He wants to dispel the sense that his way of working is as simple as a walk in the forest. “You don’t have to go outside, but can also go inside, to connect with Nature.” Going inside refers to sensing into the body in a focusing-oriented way – which invites open curiosity and acceptance, a process that opens us up to many avenues of experience, including a reminder of our lost connection to the web of life.

Children do not see the natural world as an object, says dean. Somewhere along the way, this subject-to-subject connection gets lost for many of us, creating a disconnect and a sense of dominion over animals and nature that interferes with our innate sense of belonging to it and with it. His program includes modules on dreams, focusing, nature, play, social justice and sexuality – all ways of restoring the sense of deep connection to ourselves and the natural world, both within and without.  For more information, go to hearthplace.ca

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Nightmare Distress: How we experience dreams is more impactful than what we dream

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‘Mary’, a client in my clinical practice, had frequent, bloody, violent dreams and came to love them. She once dreamt of being shot point-blank but did not find this disturbing. The feeling in the dream, and in processing it after, was peaceful, almost spiritual. Another dreamer dreamt of scenes of her family around the table simply eating dinner, yet these dreams struck terror into her heart and left her feeling upset for the entire day.

It is often the case that the emotions present in a dream are not congruent with the dream scenario. There are many reasons for this, and many implications for clinicians who ask about and work with dreams and nightmares. The main point is that emotion is a key element in the dream, possibly more important than the imagery itself.

Images in dreams can be highly dramatic, metaphorical and even fantastical. The key is what they evoke. So when asking your clients about their dreams, always inquire about the emotional landscape as well as the visual one. And also understand that dream responses are something we can work with and change.

The words of Victor Frankl (1985) come to mind here: ‘Between stimulus and response, there is a space. In that space is our power to choose our response.” We can’t change the fact that our dream forest, however beautiful, is steeped in terror (unless we become lucid, but that’s another topic). However, when we process such a dream with open curiosity, we can change how we feel about it after the fact, and over time, develop a better relationship to our dreams in general.

Mary, for example, had an intense and loving relationship to her dreams, though most of them depicted frightening or violent scenes. And as we worked with them, we discovered that these intense dreams were particularly powerful for engendering deep emotion and change. This is why, as a long-term dream therapist, I look at dream content from a not-knowing stance, never assuming a dream is as bad (or good) as it appears. Instead, I accompany the dreamer on a search for cues of safety and support, and from this place of relative comfort, the whole dream can look and feel very different from the first impression it may have made.

A recent study (Mathes et al., 2022) into nightmare distress confirms much of this clinical experience I describe. The researchers confirmed earlier findings that the level of distress a nightmare brings is significantly influenced by exposure to childhood trauma, and acutely stressful life events. However, violent dream content was less impactful for the 103 participants with frequent nightmares than the emotions they experienced in response to their dreams, a result they did not expect.

The study tracked 103 participants, 59 of whom experienced frequent nightmares, measuring dream recall, nightmare distress, levels of childhood trauma, dream emotions and violent content, and distress related to current life events. The notion that current stressors can bring nightmares, especially for those with a history of adversity, was supported and offers an explanation for the increase in nightmare frequency and distress during the worst of the global COVID pandemic, for example.

However, your response and your attitude towards such dreams can make a real difference to the level of distress they cause. A recent study by Schredl (2021) supports this idea. He found that attitudes toward nightmares and also levels of neuroticism impact how nightmares affect us. But while we can’t change our history of adversity or alter many of life’s stressors, we can change our attitudes and responses toward our dreams. The more we learn and understand about nightmares, and the more we can turn toward our dreams with calm curiosity, the less they are likely to cause distress.

The conclusion Mathes reached about nightmare distress is that “emotional appraisal has a substantial influence on nightmares. This suggests that dreamers can influence dream experiences due to their reappraisal during the dream and probably also in waking life.” My substantial clinical experience working with nightmares suggests that latter is true and may affect the former. In other words, if we befriend our dreams in waking life, we are also more likely to do so within the dreams themselves.

For example, in a few nightmare treatment sessions, I invited ‘Paula’, who experienced frequent recurring nightmares, to gather up any helpful elements she could find in her dreams. She then began to do this from within the dreams. Her nightmares were always harrowing chase scenes, but as she became more curious and comfortable with them, she developed superpowers within the dreams, such as the ability to fly away or disappear. More importantly her feelings around the dreams shifted from abject terror to a sense of adventure. And while the content of these recurring dreams still often begins in similar way, her response, both within and after the dream, has shifted to the point where she would no longer call these dreams nightmares.

 

References

Frankl, V. E. (1985). Man’s search for meaning. Simon and Schuster.

Mathes, J., Schuffelen, J., Gieselmann, A., & Pietrowsky, R. (2022). Nightmare distress is related to traumatic childhood experiences, critical life events and emotional appraisal of a dream rather than to its content. Journal of Sleep Research, e13779.

Schredl, M. (2021). Nightmare distress, beliefs about nightmares, and personality. Imagination, Cognition and Personality, 40, 177-188.

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Dreams as Doorways to Possibility

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Dreams as Doorways to Possibility:
Four ways to open up even the smallest of dreams

Have you ever been stumped by a dream? Likely all of us have experienced genuine puzzlement when we wake up with a dream image that seems utterly mysterious, too wispy to follow or simply nonsensical. We are apt to dismiss such dreams as nonsense, or as not profound enough to warrant our attention. However, if you consider dreams as openings for further exploration, every dream is worthy of our attention.

In my year-long experiential dreamwork program, I always spend a session exploring dream ‘snippets’ as a way to illustrate how much can come of mere wisps of dreams. It helps to consider a dream as a doorway to a much larger world of experience. Or like the thread from the Greek myth by which Ariadne left a trail enabling her lover to escape the maze of the Minotaur. The end of the thread, the snippet, does not give us the whole picture, but rather, a way forward. The destination is not yet known, but ultimately might lead to greater freedom.

In this article, I offer a few different ways that you can explore any dream, big or small, in a way that opens to new possibilities.

Dreams as picture-metaphors for emotion
My dreams often come as single images without much of a story. They can be a simple picture, and for the person guiding me in a dream process, it may feel like there isn’t enough to work with. For example, I dreamt of an old-fashioned pair of crossed wooden skis. Considering Ernest Hartmann’s idea that dreams are metaphors for salient feelings, already something opens up. There is a sense of motion that is stopped, possibly because of an outdated way of doing things, or maybe because I am ‘cross’. Yes, I can feel some old anger I hadn’t realized was present…

The other thing that occurs to me is that these skis can still work and have served someone very well. They have been well-used, and I sense, well-loved. In Hartmann’s way of working, this feeling might correspond to something current and salient in my life, so further inquiry could head in that direction.

Dreams as bringing a bodily felt sense
Another way to deepen understanding of any dream image is to try a focusing approach, as offered by Eugene Gendlin. This involves getting a bodily felt sense of the image, and letting it open up from the inside. Like Ariadne’s thread, such a process can lead to new territory entirely, with the image as the starting place.

A felt sense of the skis, for example, takes me to a crossed place in my chest, but also an awareness of potential movement. The skis, of their own accord, want to uncross and be placed on the snow. Their essence speaks of forward motion and speed. I begin to feel an expansive sense in my chest, and am infused with enlivening memories of my cross-country skiing exploits. Rather than get lost in those, I go back to the felt sense (which is what I would do if I were guiding a dreamer here). I’m getting a message that feels like an unblocking, an opening and a sense that the way forward is available, and both awkward (old skis) and exhilarating.

Dreams as doorways
Carrying this little image forward in another way, I might explore the environment of the dream, and then venture out into it. This is a Jungian approach, called active imagination. You can take any dream image as a place to begin and then open up the setting or dream landscape.

My skis seem to be in the wall of a rustic cabin, and there is a sense that it might be an earlier time. These skis are not obsolete, but in fact, more an essential means of getting somewhere. There are now some old-fashioned boots and poles are nearby, and I see a skier breaking trail through a foot of fresh snow. The trail is flat, wooded, and inviting. There is the sense of a journey, but one the skier is very prepared for. In exploring this dream image, we can follow this trail as far as we like, potentially meeting challenges and helpful characters along the way.

Associating to dream images
The last opening I will suggest here is that of association. This is a more traditional way of exploring dream images, and one that I tend to use lightly. This is because the process of asking what memories or stories from our life are brought to mind by a dream image can sometimes lead us away from the essence of the image and into webs of memory that limit rather than open what we experience from the dream.

Associations to the skis are of fancy cabins that hang such skis on the wall as decoration. I also recall a pair of leather ski boots my dad used to own, and a childhood memory of trying to ski on flat ground in huge old skis and not getting very far. I also associate to skiing in general, which I love. To me, these images feel less generative than the methods listed above that open up the image via experiencing and imagination. Such is my personal bias. Associations can also be powerful.

My suggestion is to try any of these methods that appeal to you. Next time you wake up with a puzzling dream image or snippet, one you are tempted to dismiss, play with these avenues. Or if a client brings a dream that feels too thin and unsubstantial, try these ways of helping them to use the image as a leaping off place to a world of possibility.

DREAM CIRCLE Dec. 4: Dreams as doorways to possibility
Our last Dream Circle of 2022 will focus on imaginative and experiential ways that even the smallest of dreams can open the dreamer up to possibility. See the article above for a fuller description of the avenues we will explore as a group. This group is open to all graduates of my experiential dreamwork and focusing programs. More info here.

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Dreams as a picture of the nervous system

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Dreams as a picture of the nervous system, and an avenue for state shifts

It’s beginning to dawn on me that not just nightmares, but all dreams can be seen as an expression of the nervous system. They are images direct from the body, far less filtered by our internal censor than waking thoughts — they are more image-based, more visceral and fluid. Spending time with our dream images in a calm and curious way can be inherently regulating, and I am beginning to suspect why this is so.

The late Ernest Hartmann, a celebrated dreamworker and researcher, said two things that I want to follow up on in this context. The first is, “The nightmare is the most useful dream.” This is not meant to dismiss the real distress and terror that our worst dreams can bring. It’s that nightmares represent an extreme state, and as such, one that we can learn the most from.

Linking nightmares and the nervous system

I’ve spent the last couple of years investigating the link between nightmares and the autonomic nervous system (ANS) through the lens of polyvagal theory. Although I think the implications of this for nightmare formation and treatment are still largely unexplored, I started this ball rolling with the recent publication of an article with the optimistic title, Solving the Nightmare Mystery in which I imply that the role of the nervous system is a missing link in our understanding of how to treat nightmares (Ellis, 2022).

I have been sitting with those who experience deeply disturbing dreams for many years now, one of the main things I do to help is facilitate the search for, and embodiment of, cues of safety that help alter their perception and experience of these dreams. They tell me this embodied process of dreaming their dreams forward (called ‘rescripting’ in modern nightmare treatment literature), changes how they hold the dream in their body. Typically, the memory remains, but the charge dissipates, after a successful session.

Nightmares are dramatic, and there is clear autonomic activation during sleep state shifts for those who experience them frequently. Nightmares are easily recalled and their impact is tangibly felt, as is the relief one experiences when they begin to fade or shift into a more benign form. This is useful because when a phenomenon is loud and colorful, we can more easily see it.

Dream images as nervous system state and shifts

However, in a recent class I teach on the clinical use of dreams, a dreamer brought an image of a dark, still woman in a tub that had sat so long the water had gone cold. Her impulse, in dreaming this forward, was to turn on the hot water faucet, to bring some warmth to the bath and to the woman’s body. Entering the dream further, she noticed the tub itself, and it was older, more ornate and beautiful than the one is her current bathroom, where the dream was set. Her own demeanor changed in this process or warming the bath, her face coloring and smiling as she described making the bath a sanctuary, adding scent and oil and dipping into the enjoyment of it. Later, she told me the shifts continued in the coming days: “I continued to experience “mini shifts” in the following days and was able to access and carry the felt sense of the warmth and beauty of the bath into many areas of my daily life. I noticed I feel more present when I bring a sense of aesthetics, in the form of a little beautifying and warming detail, when I have to tackle some of the mundane daily tasks and responsibilities, which were weighing me down lately.”

This entire dream process could be seen as an image of the nervous system as it shifted from a cold, immobilized (dorsal vagal) state, into one of connection and animation that was clearly visible on her face. Her fellow classmates remarked on the change, as her physiology demonstrated a clear shift into a state of social engagement and warmth (ventral vagal). This kind of shift is typical in working with dreams. The images from nightmares are clear representations of autonomic states. Activation or fight/flight – being chased or engaged in a battle – are some of the most prevalent nightmare themes. The leap I have made is simply that nightmares are the most obvious expression of what happens in all dreams. They are our bodies expressing in image and sensation our fluctuating internal state. They are doorway into its expression, particularly valuable for those who have trouble hearing what’s going inside.

Dreamwork as a way to metabolize and regulate emotion

This brings me to another of Hartmann’s famous statements: that dreams are a ‘picture-metaphors’ for our most salient emotional concerns. Sometimes our most pressing feelings are repressed, historic or fleeting enough that we don’t think about them during the day. But our dreams have an uncanny way of picturing what matters most, even if we have repressed it. Our bodies carry the charge of feelings and memories that are unmetabolized, and these find expression in our dreams.

My sense, which is shared with many dreamworkers and researchers, is that a purpose of dreaming about emotion is not to upset us but to help us process and shift such feelings. Sometimes, the dreams do this all on their own, like a nocturnal therapist, and sometimes it really helps to have another person process the dreams with us. One idea that attention to the nervous system and polyvagal theory has taught us is that we humans (and all mammals) function better together than alone. Sharing our dreams and bringing them into company and the light of day helps them do their job better. And more and more, I’m beginning to think that a large part of their job is expressing and regulating the state of our nervous system.

 

References

Ellis, L. A. (2022). Solving the nightmare mystery: The autonomic nervous system as missing link in the aetiology and treatment of nightmares. Dreaming.

Hartmann, E. (1999). The nightmare is the most useful dream. Sleep and Hypnosis, 1(4), 199-203.

Hartmann, E. (2010). The dream always makes new connections: the dream is a creation, not a replay. Sleep Medicine Clinics, 5(2), 241-248.

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Nightmares Quadruple Adolescent Suicide Risk

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Nightmares quadruple suicide risk in youth, yet overlooked by most clinicians

Scary dreams are common among children, and possibly it is for this reason that they are often overlooked by clinicians. In fact, frequent nightmares can indicate a life-threatening state. It has been well established that nightmares are robustly linked with higher suicide risk in adults, and a recent study has extended this to adolescents.

Children with frequent nightmares are twice as likely to consider suicide and four times more likely to attempt it than kids with fewer nightmares. It’s normal in childhood to have some nightmares, but frequent, chronic, distressing dreams indicate nightmare disorder, which warrants clinical attention, something too few nightmare sufferers receive.

 

Clinicians drastically underestimate nightmare prevalence

In a recent study, Corner and colleagues (2022) looked at reported rates of nightmare disorder among 806 child psychiatric outpatients, asking both children and their parents about prevalence of nightmares. The researchers found that parents reported 40 percent of these children had nightmares, while 56 percent of the children said they had experienced a nightmare the previous week. Of these children, just 12 (0.01%) had been diagnosed with nightmare disorder, and 16% were given a posttraumatic stress disorder (PTSD) diagnosis. It appears parents underestimate the prevalence of their childrens’ nightmares by a little, and clinicians underestimate by a lot – if they consider nightmares at all.

The researchers found that very few children in this sample with chronic nightmares had been identified, yet many families expressed desire for treatment for their children. Their conclusion: “We join with researchers of adult populations in calling for routine screening of nightmares.”

A recent systematic review of the prevalence of nightmares in youth found that in clinical populations, 27% to 57% reported nightmares in the previous week and 18% to 22% in the previous month (El Sabbagh et al., under review). By contrast, 1% to 11% of those without a clinical diagnosis reported having a nightmare in the previous week, and 25% to 35% in the past month. Clearly, nightmares are highly prevalent in those children with mental health concerns.

 

Childrens’ nightmares are highly prevalent, mostly undiagnosed, yet treatable

The hard part of this story is that so many of those with nightmare disorder are undetected and therefore untreated, despite the availability of effective therapies. For example, a recent study looked at treatment of childrens’ nightmares using a sample of 17 children aged 5 to 17. While the researchers were exploring some of the nuances of such treatment, the first important point is that the treatment was effective, with high effect sizes across the board.

The sample was too small to draw firm conclusions about the efficacy of the treatment used – five cognitive-based sessions, including psychoeducation and rewriting the nightmare. However, it does support the considerable evidence that nightmares are treatable.

In this particular study, Pangelinan and colleagues (2022) wanted to know which was reduced first during treatment: nightmare frequency or distress. Because the distress caused by nightmares is considered a driving force in recurrent dreams, the researchers expected distress to drop before frequency, but found the opposite to be the case. Yet both factors were steadily reduced over time, after an initial spike in the distress levels, possibly caused by focusing on the nightmares more than usual.

What makes nightmare treatment effective continues to be a bit of a puzzle and potentially many factors contribute to the success of treatment. I suggest, in my recent article on nightmares and the nervous system (Ellis, 2022), that it is a sense of safety at a physiological level that could underlie nightmare treatment success, and this can be achieved in many ways. Some of these factors are alluded to by Pagelinan: “The steady decline of nightmare frequency and distress over time supports the idea that nightmare treatment is not about an on-off switch of sorts but rather a process by which different skills that address efficacy, hope, relaxation, and sleep skills, in addition to the emotion processing of a nightmare through exposure and rescription, may be important in nightmare treatments.”

The main point here is that while there are many more things to understand about how to treat nightmares, we know enough already to make a real difference. The larger problem we currently face is lack of awareness that nightmares are so prevalent in the clinical population, and that they represent both risk and opportunity.

I am offering a more comprehensive course for clinicians called The Nightmare Treatment Imperative.  Learn why treating nightmares is both essential and surprisingly simple.

 

References

Cromer, L. D., Stimson, J. R., Rischard, M. E., & Buck, T. R. (2022). Nightmare prevalence in an outpatient pediatric psychiatry population: A brief report. Dreaming. Advance online publication. https://doi.org/10.1037/drm0000225

Ellis, L. A. (2022). Solving the nightmare mystery: The autonomic nervous system as missing link in the aetiology and treatment of nightmares. Dreaming.

Pangelinan, B., Rischard, M. E., & Cromer, L. D. (2022). Examining changes in nightmare distress and frequency across treatment in a child sample: Which improves first? International Journal of Dream Research, 15(2), 198-204.