Category: Clinical Practice

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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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What Can You Do About Your Nightmares? Ideas from a trauma expert

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There is a lot you can do, and some compelling reasons why you should take action to quell your nightmares, especially if you suffer from post-traumatic stress injury

Tom is awakened with a start by the sound of his own screams. Several nights a week in his dreams, he revisits the burning building, and hears terrified voices from inside, above the roar of the flames. The building has been deemed unsafe, he can only watch in frozen terror as the heavy beams start to fall and the building collapses. This is not an actual memory, but a condensation of all the times in his career as a firefighter that he arrived on the scene too late to save someone. Now, these memories haunt his dreams, and bring a deep sense of despair. What most people do not realize is that you do not need to simply suffer them; there is something you can do about nightmares.

Not all nightmares are a cause for concern

Nightmares plague almost all of us at different times in our lives. For the most part, this is not a problem, even though such dreams can be distressing. But if your nightmares cause significant distress, wreak havoc on sleep and adversely affect how you function during the day, it is really important to do something about your nightmares. About 5% of the general population and 30% of those with some form of mental illness fall into this category.

Researchers have established a clear link between nightmares and suicide, so if you have both suicidal thoughts and nightmares, you need to take action. Fortunately, what many people don’t realize is that there are many effective treatments for nightmares and they involve fairly simple steps. (If your therapist does not have training in nightmare treatment, some accessible online resources are listed below.)

Talking about your nightmares helps

Too few people talk about their nightmares; there is a tendency to think this wouldn’t help. Or that those you tell will judge you. Neither is true, and it really helps to talk about nightmares. Nadorff has studied nightmares extensively and concludes that “nightmares are a robust and modifiable predictor of increased suicidality and poor psychiatric outcomes” (2015, Journal of Clinical Sleep Medicine).

The good news is that nightmare treatment appears to work for many people. The research has raised many questions about what exactly is working and why, but it seems that almost anything that researchers have tried has the potential to make a difference. It may be that simply knowing nightmares can be treated opens the doorway to change.

Nightmare rescripting is the common denominator

There are many elements that have been incorporated into nightmare treatments. One of the most common is called nightmare rescripting. This is simply the process of coming up with a new ending to your nightmare. In the well-researched treatment modality called Imagery Rehearsal Therapy, people are asked to change their nightmare in any way they want, and then to imagine this new version a number of times before going to sleep. The research has shown this to be very helpful for many kinds of nightmare sufferers, from veterans to rape victims.

There are many variations on this treatment, and all appear to be helpful. I found in my practice that teaching clients to imagine a new ending to their nightmares is something they can do on their own, at home right when they wake up from a frightening dream. This gives them a constructive action to take, a way of calming down. They tell me it gives them a sense of control over their distressing dreams and takes away some of the fear of going to sleep. What is also good about such nightmare treatments is that they can not only help reduce nightmare frequency and distress, but they also reduce daytime symptoms of posttraumatic stress injury – things like flashbacks and a tendency to avoid situations that can trigger them. The other good news about most of the nightmare treatments studies is that treatment is quick, can make a difference in a session or two, and even if doesn’t help as much as you would like, the studies reported few if any adverse effects.

What to do when you wake up from a nightmare

When you are jolted out of sleep by a nightmare, your body will likely be quite amped up. So take a few minutes to let your heart rate and breathing slow down. Remind yourself gently that this was just a dream, and that it is not happening now, real as it may have seemed a few moments ago. Take a few long, deep breaths, extending the exhale to calm your nervous system. Calm your emotions by picturing in detail one of your favorite places or imagining someone you love deeply and amplifying the feelings you have about them. Look around the room for something comforting and to remind yourself you are safe in your bedroom, not back in the dream.

Once you feel calmer and better, go back to your nightmare images, just the very last part of the dream that woke you up, and allow the dream to play forward from there in any way you want. It does not have to come to a tidy resolution, although it might. Just let the dream play forward to find a better stopping place. Keep your breath slow and regular. What most people find is that this simple practice changes the dream for the better and gives the dreamer a greater sense of control and safety.

Nightmare changes can indicate trauma recovery

When I have treated patients with nightmares in a similar way to what is described above, I found that all of them experienced some kinds of changes in their dream life. Sometimes the nightmares stop altogether, but more commonly, they begin to change and start to look more like normal dreams – they are a bit stranger, more a of mix of past and present, and less of a direct replay of a trauma memory. This is an indication that the process of healing has begun.

When a traumatic event has not been metabolized, it can come back in the form of recurrent dreams that either represent or replicate the actual trauma event. The more the dreams of the trauma begin to weave in elements from current life, the closer the dreamer is to having integrated their trauma. The nightmares may not stop right away, but if they shift and start to feel more like normal dreams rather than repeated replays, this is a good sign.

Resist the urge to avoid treating nightmares

Both therapists and those who suffer from nightmares might be tempted to back away from conversations about their alarming content. But if you are suffering from the same kinds of terrifying dreams most nights, it is a mistake to think not talking about it will help in some way. It does not. Talking about it helps, even when the subject matter is intense.

Philosopher Eugene Gendlin said it this way: “What is true is already so. Owning up to it doesn’t make it worse. Not being open about it doesn’t make it go away… People can stand what is true for they are already enduring it.”

Current research has shown that even with the most unbearable trauma, such as those who were inmates of Auschwitz, it is better for survivors to talk about their dreams than try to bury them. A Polish researcher, Wojciech Owczarski, studied 500 dreams of 127 former inmates and found that only 10 percent are still suffering from recurrent dreams that replicate their trauma. He found that all the dreams had “therapeutic potential” either on their own or with the help of a therapist.

To wrap up, there are many reasons to talk about your nightmares, to rescript them, and to seek treatment if they cause you significant distress. These challenging dreams can be seen as your own body’s attempt to integrate the trauma you have suffered, but to realize this helpful effect, you must work with the dreams rather than avoiding them.

 

As a small gift to those who suffer from nightmares, I have made a free 7-minute self help video, dedicated to first responders and front-line workers. For those clinicians who want more information on treating nightmares, consider taking my online course: Nightmare Treatment Imperative.

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Does Your Child Have Nightmares?

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When should you be concerned, and what should you do?

All of us can clearly recall at least one heart-pounding, fear-inducing nightmare from childhood that startled us out of our sleep. Whether it was a chasing dragon or a precipitous fall from a great height, it felt so real it left us shaken long after awakening. However, as adults we know that there isn’t a monster under our beds waiting to snatch us, even if we just dreamt about one. For children, nightmares can be confusing because they feel so very real. And as young children, the line between fantasy and reality is blurred,

Nightmares are completely normal phenomena, especially for children. They usually begin between age 2-4 and tail off by age 10-12. They are a developmental process and are a normal response to fear. They can be triggered by stressful events like starting school, family illness or conflict. In fact, nightmares can actually help process emotional events.

However, despite their potential to be helpful, nightmares do cause considerable distress and can disrupt sleep. So how can you help your child if they have frequent and distressing dreams?

  1. OFFER COMFORT AND SAFETY

Give them a hug, let them know they’re safe, that they’re not alone. Their nervous system is in a charged state. They need soothing to restore a sense of safety in their bodies.

  1. DON’T DISMISS DREAMS

Don’t try to talk them out of their experience or dismiss their dream using logic. In an attempt to offer comfort, don’t say, “It was just a dream, it’s not real” and expect that to be the end of it. Children experience their dreams as very real, and for certain, the intense feelings nightmares stir up are tangibly experienced.

  1. NORMALIZE TALKING ABOUT DREAMS

Ask your child about their nightmares. If they feel okay telling you about it, listen to the story of their dream. Sharing it with you will help take away some of the charge. It gives them a way to talk about their fears. There may be pressures they are facing that you have no idea about. Growing up is fraught with uncertainty and challenges that may seem inconsequential from an adult perspective.

Some children rarely articulate what’s scary for them, so we don’t get a chance to dispel needless worries or offer help. But their nightmares can do the talking for them in the form of metaphors and expressions of their main concerns.

Keep tabs on your child’s dream life, especially if it seems unusually dark and disturbing. If you make talking about dreams a normal part of the routine, you’ll know how often your child has nightmares and how distressing they are. You’ll be in a good position to know if professional help is warranted. And you will have gathered useful information to convey to a therapist about your child’s sleep.

  1. WHEN TO CONSIDER PROFESSIONAL HELP

Nightmares are considered chronic if they happen every week or more for at least 6 months. Fully 5% of children between the ages of 3-10 experience chronic nightmares, and for many, this is a normal developmental process. However, if chronic nightmares persist past about age 10, they are more likely to continue into adolescence and beyond. Age 9-11 is a critical juncture, a time to consider treatment if your child continues to have frequent, distressing nightmares.

Fortunately, effective treatment is available.

Imagery Rehearsal Therapy, (IRT) has been found to be effective in numerous controlled clinical trials in adult populations (ie with veterans and rape victims). This evidence has also been extended to children in a number of smaller studies that have shown it to reduce nightmare frequency, distress and general anxiety in children. Results were sustained 6-9 months post-treatment.

Imagery Rehearsal Therapy (IRT) is the most highly-recommended approach to nightmare treatment for any age group. Other protocols, like Exposure, Relaxation and Rescripting (ERRT) appear to work as well, but have simply not been studied as much. IRT is a non-invasive, cognitive behavioural approach that simply asks the dreamer to imagine and rehearse a new dream ending. This seeds a new story that often weaves its way into future dreams. One study showed that some children using IRT spontaneously became lucid after treatment and were able to alter their nightmares from right inside the dream.

  1. TRY DREAM THERAPY AT HOME

The original protocol for IRT suggests changing the dream in any way you want. However, for children, I recommend asking them the shift the dream in ways that help them feel better about the dream, ideally ways that bring a sense of hope and mastery.

To try your own version of this approach, first help your child feel safe and calm. Then ask them to recall their nightmare briefly, perhaps just up to the place where they might want something about the dream to change. Then ask them what they imagine could happen next in the dream to make the dream better. For example, ask what form of help, escape route, magic or superpower they might want to use. Let them know it’s their dream, and they can change it it any way they like.

For example, suppose your child dreams there is an evil monster under the bed, lurking and waiting for a limb to dangle over the edge so it can grab an arm or leg and drag them under. You could ask your child to imagine going back into their dream, to the part before it got scary. They could change the dream so what’s now under the bed is a favorite toy, perhaps a cuddly teddy bear that comes to life and takes them off to play in the clouds.

Or they might dream of a fire-breathing dragon chasing them. Often, it can really help to turn and face the dragon or monster, to really see it and perhaps ask what it wants. I did this with my daughter, reminding her of how I often sang Puff the Magic Dragon to her at bedtime. Her dream dragon became like Puff — lonely and in need of a friend. When playing with how to rescript nightmare, encourage children to give their imagination free rein, offer suggestions and keep it positive.

After rescripting, a further step in IRT is to rehearse the new dream ending, something children may need to be reminded to do. You can do a number of things to reinforce the new dream imagery for a child. You might suggest they draw a picture of it, imagine it again during the day, and/or tell you about it again as you tuck them in at bedtime.

What happens when we reimagine our nightmares or help our kids to do so? Sometimes the new dream ending becomes incorporated into future dreams, making them less frightening. Other times, people report a new ability to change their dreams from within. And sometimes the nightmare just stops coming. If the process doesn’t work the first time, try again, and play with different dreams as they come up. Do seek professional help if chronic nightmares persist or the process itself is upsetting (this is extremely rare). With the right support, and in time, your child will have fewer, less distressing nightmares. They may even come to cherish their dreams.

 

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

 

References

Fernandez, S., DeMarni Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A Case Series: Cognitive-Behavioral Treatment (Exposure, Relaxation, and Rescripting Therapy) of Trauma-Related Nightmares Experienced by Children. Clinical Case Studies, 12(1), 39–59. https://doi.org/10.1177/1534650112462623

Mélanie St-Onge, Pierre Mercier & Joseph De Koninck (2009) Imagery Rehearsal Therapy for Frequent Nightmares in Children, Behavioral Sleep Medicine, 7:2, 81-98, DOI: 10.1080/15402000902762360

Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009). Factors affecting nightmares in children: parents’ vs. children’s ratings. European child & adolescent psychiatry, 18(1), 20–25. https://doi.org/10.1007/s00787-008-0697-5

Schredl, M., Fricke-Oerkermann, L., Mitschke, A. et al. Longitudinal Study of Nightmares in Children: Stability and Effect of Emotional Symptoms. Child Psychiatry Hum Dev 40, 439–449 (2009). https://doi.org/10.1007/s10578-009-0136-y

Simard, V., & Nielsen, T. (2009). Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy: Theory, Research, Practice, Training, 46(4), 492–497. https://doi.org/10.1037/a0017945

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Does Your Child Wake Up Screaming? How to understand and treat night terrors

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I used to dread going to bed when we lived in my lovely heritage apartment in Vancouver. Every night, about two hours after falling asleep, I would be startled awake by the most blood-curdling, agonizing screaming from the woman next door. Her window faced ours, and she sounded as though she was being murdered in her sleep almost every night. I wondered why no one would wake her up or help her. I have since learned that this would not have done much good as she was having night terrors.

So many people I’ve spoken with about this have suffered the same thing with their children. Night terrors are fairly common in very young children, affecting 20-40% of children under age 3, and 3-14% of school age children, but just 2% of adults (APA 2013). In a typical episode, parents will put their child quietly to bed only to hear them thrashing and screaming in terror about three hours later. The kids were hard to fully wake up, disoriented and confused, often with little or no memory of the incident in the morning.

Night terrors are often mistaken for nightmares. At a recent talk I gave about nightmares, most of the questions were actually about night terrors – from desperate parents wanting to know if there was something they could do about them. I treat nightmares, not night terrors, but I did some investigation, and there are a few things to know and to do that can help. First and foremost, know that they are generally benign and kids usually grow out of them.

Who Has Night Terrors?

Before I get into some of the ways you can help your child with their night terrors, it helps to understand what they are, who has them and why. A thorough survey of the literature suggests that although the exact cause is not well understood, genetic, developmental, environmental, psychological and organic factors can all play a part.

Night terrors most common in early childhood. A longitudinal study (Petit et al., 2015) of 1,940 children from Quebec found that 34% of children aged 18 months experience night terrors, 13% at age 5, and 5% at age 13. A recent review (Leung et al., 2020) found the peak may be later, at age 5-7 years. Either way, sleep terrors typically start at a very young age and stop at adolescence. It’s rare that the condition continues into adulthood – although for some it can switch to sleepwalking.

Sleep terrors are more common under a number of conditions that can be controlled, at least to some degree, such as: sleep deprivation, going to bed with a full bladder, emotional stress, anxiety (including separation anxiety), bullying, a noisy sleeping environment and excessive alcohol or caffeine. Other factors associated with this parasomnia include: febrile illness (unexplained fever), ADHD, autism, epilepsy, sleep apnea and PTSD. Some medications, especially those that are sedative, can lead to night terrors because they increase the duration of non-REM, the deep sleep stage in which these episodes occur.

It bears repeating the while night terrors are very distressing and can disrupt sleep for both children and their parents, they are not considered dangerous. They warrant clinical attention only if they are severe enough to disrupt daytime functioning. If you are considering consulting a doctor, keep a sleep diary and track BEARS. Not the big furry animal, but the 5-item assessment tool for children with sleep problems (Owens & Dalzell, 2005):

  • B: bedtime issues
  • E: excessive daytime sleepiness
  • A: night awakenings
  • R: regularity and duration of sleep
  • S: snoring

What Are Night Terrors?

In a typical episode, the child will sit bolt upright or even jump out of bed, heart racing, screaming in terror. They may speak, but what they say will be confused and incoherent because although they appear to be awake, they are in a hybrid sleep-wake state. They will be difficult to wake fully because these episodes occur during very deep (slow-wave) sleep. It’s best not to wake them up during an episode, and typically they won’t recall a thing in the morning.

Night terrors are distinguished from nightmares because they happen in the first half of the night associated with the deeper (stage 3 and 4) of non-REM sleep, while nightmares mainly occur in the second half, and are associated more with REM sleep and dreaming. Nightmares are clearly recalled in vivid detail, and those who have them tend not to thrash around and scream.

Night terrors are much more common in children. When they continue into adulthood, they look a bit different. While two-thirds of children have no recollection after episodes of night terrors or sleepwalking, the same proportion of adults do recall at least one experience and remember their episodes about half the time (Castelnovo, et al., 2021). For adults, night terrors appear to be more of a dissociative experience, and can be accompanied by hallucinations.

What you can do about night terrors

While none of the suggestions below work all the time, there are a number of things you can try to reduce or even eliminate night terrors. Excellent sleep hygiene (such as regular bedtimes; limiting screen time, no food and drink before bed, especially sugar and caffeine; dark, cool quiet bedroom; and wind-down rituals like story time) can all help reduce night terrors. Parents can also do their best to limit stresses on kids who have night terrors – things like bullying and separation anxiety might be addressed. Interestingly, psychological factors are found to be mostly associated with night terrors in teens and adults, but not children.

Wake-up treatment. One treatment that has met with some success is to wake a person up about half an hour before they would typically have an episode. If you do this for two weeks, it can break the cycle and stop it from recurring. In some cases, however, the episodes simply start occurring later in the night.

Co-sleeping. One interesting paper (Boyden, Pott & Starks, 2018) suggests that sleeping with your child stops night terrors, especially with very young children. The authors say that evolution did not design humans to sleep alone when very young and that “night terrors are the result of an environmental mismatch between evolved behaviour and the modern cultural practice of solitary sleeping.” This solution has not been empirically tested, but anecdotally, it appears to work for many.

The bottom line is that while night terrors can seem extreme, they are usually benign and your child will experience them less and less over time. There are a number of things you can try, such as good sleep hygiene, limiting stress, waking them prior to an episode and co-sleeping. To all those exhausted parents reading this, I hope it has been of some help.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davey, M. (2009). Kids that go bump in the night. Australian Family Physician, 30, 290- 294.

Ekambaram, V., & Maski, K. (2017). Non- rapid eye movement arousal parasomnias in children. Pediatric Annals, 46, e327-e331. doi:10.3928/19382359-20170814-01

Golbin, A.Z., Guseva, V.E., & Shepovalnikov, A.N. (2013). Unusual behaviors in sleep as “compensatory” reactions aimed at normalizing the sleep–wake cycle. Human Physiology, 39, 635-641. doi:10.1134/ S0362119713060042

Ivanenko, A., & Johnson, K.P. (2016). Sleep disorders. In M.K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (2nd ed.). Arlington, VA: American Psychiatric Publishing.

Laberge, L., Tremblay, R.E., Vitaro, F., & Montplaisir, J. (2000). Development of parasomnias from childhood to early adoles- cence. Pediatrics, 106, 67-74. doi:10.1542/ peds.106.1.67

Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Lun Hon, K. (2020). Sleep terrors: an updated review. Current Pediatric Reviews, 16(3), 176-182.

Murphy, P.J., Frei, M.G., & Papolos, D. (2014). Alterations in skin temperature and sleep in the fear of harm phenotype of pediatric bi- polar disorder. Journal of Clinical Medicine, 3, 959-971. doi:10.3390/jcm3030959

Nguyen, B.H., Pérusse, D., Paquet, J., Petit, D., Boivin, M., Tremblay, R.E., & Montplaisir, J. (2008). Sleep terrors in children: A prospective study of twins. Pediatrics, 122, e1164- e1167. doi:10.1542/peds.2008-1303

Petit, D., Pennestri, M.H., Paquet, J., Desautels, A., Zadra, A., Vitaro, F.,…Montplaisir, J. (2015). Childhood sleepwalking and sleep terrors: A longitudinal study of prevalence and familial aggregation. JAMA Pediatrics, 169, 653-658. doi:10.1001/ jamapediatrics.2015.127

Salazar, F., Baird, G., Chandler, S., Tseng, E., O’Sullivan, T., Howlin, P.,…Simonoff, E. (2015). Co-occurring psychiatric disorders in preschool and elementary school-aged chil- dren with autism spectrum disorder. Journal of Autism and Developmental Disorder, 45, 2283- 2294. doi:10.1007/s10803-015-2361-5

Silvestri, R., Gagliano, A., Aricò, I., Calarese, T., Cedro, C., Bruni, O.,…Bramanti, P. (2009). Sleep disorders in children with attention- deficit/hyperactivity disorder (ADHD) re- corded overnight by video-polysomnography. Sleep Medicine, 10, 1132-1138. doi:10.1016/ j.sleep.2009.04.003

Wolke, D., & Lereya, S.T. (2014). Bullying and parasomnias: A longitudinal cohort study. Pediatrics, 134, e1040-e1048. doi:10.1542/ peds.2014-1295

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

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Sleep quality and PTSD: A bidirectional link

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If you want to effectively treat PTSD, it’s critical to address sleep issues, including nightmares. Currently, there is too little integration of sleep and trauma-focused therapies for the treatment of PTSD according to the authors of a comprehensive review of sleep disorders and PTSD. Weber and Wetter’s (2021) survey of the literature shows that intervening in sleep disturbances also helps daytime PTSD symptoms and may even offer a preventative effect.

 

Sleep problems, a core feature of PTSD, include nightmares, insomnia and nocturnal anxiety. The authors found little evidence for the long-term effectiveness of medication for insomnia and nightmares and called for a more complex and integrated approach to psychological treatment. They stress the importance of addressing sleep issues, noting that sleep problems and PTSD have a bidirectional link. Sleep issues can predispose a person to PTSD and perpetuate it.

 

“Interventions that enable people to sleep better are likely to be of particular therapeutic importance, as they may have immediate remedial effect on PTSD symptoms,” according to the authors. More than 90 percent of those with PTSD also have sleep problems that include post-traumatic nightmares, and difficulty falling and staying asleep. They can also ruminate at night, talk in their sleep, wake up disoriented and suffer from parasomnias.

 

PTSD associated with alterations in the nervous system and sleep architecture

There is much evidence to show that those with PTSD have low parasympathetic tone while awake and resting, and increased sympathetic activation during sleep, especially during REM when most dreaming occurs. It is now considered established that altered heart-rate variability (HRV), a measure often used to assess the state of the nervous system, increases the likelihood of developing PTSD after trauma.

 

The sleep patterns of those with PTSD differs in many measurable ways from normal, healthy sleep, indicating they sleep less deeply, and spend less time in restorative, regulating slow-wave sleep. Sleep spindles, bursts of brain activity that can be seen on EEG readouts during stage 2 non-REM sleep, are associated with memory consolidation and neuroplasticity. These are altered in those with PTSD sufferers. Similar disruptions in sleep spindle patterns were also found recently in those with nightmares associated with early childhood adversity – a finding that suggests trauma nightmares and so-called idiopathic nightmares (of unknown origin) may not be so easily differentiated (Nielsen et al. , 2019). REM sleep patterns are also altered in PTSD in ways that fragment this dream-rich phase of sleep that has been shown to help regulate emotion and attenuate fear and distress.

 

Sleep disturbances are linked to increased suicidality and self-harming behaviours. PTSD is also a risk factor for suicide. Weber and Wetter (2021) note that reciprocal influences of sleep, PTSD and suicide are well documented but not well understood. They do, however, cite a study that suggests “targeted treatment of sleep disorders and nightmares could contrubute to reducing the risk of suicidality in PTSD patients (Bishop et al., 2020).

 

Treatment of PSTD and Sleep Disorder Must Be Integrated

While PTSD treatment helps with insomnia and nightmares, and treatment of sleep problems helps with daytime PTSD symptoms, the two approaches are rarely integrated. The authors note several effective psychotherapeutic approaches to treating nightmares, including IRT, ERRT and EMDR. They also review pharmacological interventions, and the evidence is less favorable. They also studied the impact of sleep inteventions post-trauma as a way to prevent PTSD, and again the evidence was not conclusive.

 

In their conclusions, Webe and Wetter say there is “robust evidence” for psychotherapeutic inteventions and less evidence for medication as a treatment for PTSD. “Integrative concepts and optimized algorithms for sleep and daytime symptoms are needed.” These may also help reduce the risk of suicide, and in future, even prevent the development of PTSD following trauma.

 

References

Bishop T. M., Walsh P. G., Ashrafioun L., Lavigne J.E., Pigeon W. R. (2020). Sleep, suicide behaviors, and the protective role of sleep medicine. Sleep Medicine, 66, 264–70.

Nielsen T., Carr M., Picard-Deland C., Marquis L. P., Saint-Onge K., Blanchette-Carriere C., et al. (2019). Early childhood adversity associations with nightmare severity and sleep spindles. Sleep Medicine, 56, 57–65.

Weber, F. C. & Wetter, T. C. (2021). The many faces of sleep disorders in post-traumatic stress disorder: An update on clinical features and treatment. Neuropsychobiology, published online Seot. 2. DOI: 10.1159/000517329

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

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Veterans and dreams: Special considerations for treating moral injury and lucid nightmares

By Dr. Leslie Ellis

Sometimes, traumatic injury is not just an overwhelming event, but one that constitutes a deep moral injury. This kind of trauma, more common among veterans, requires a uniquely sensitive approach. At the most recent conference for the International Association for the Study of Dreams (IASD, June 2021), keynote speaker Eduardo Duran, addressed the complexities of treating the moral injury many veterans suffer – where trauma is not just about what you have witnessed and experienced, but also about things you have done or failed to do in the context of battle, where the usual societal rules do not apply. Taking the life of another or failing to save someone’s life, for example, may lead to devastating moral injury.

 

An indigenous perspective on treating moral injury

Duran brings an indigenous perspective to the question of moral injury, and speaks of the importance of redressing balance. A moral injury refers to an act that weighs heavily on one’s conscience, characterized by profound guilt and shame. In his book, Healing the Soul Wound (2019), Duran writes of the indigenous teachings which say there is an agreement or contract made when one warrior takes the life of another. “Taking anything requires that a balancing act occur in order to harmonize the action. Everything in the universe seeks balance, and actions taken in any situation will either balance themselves unconsciously through the manifestation of symptoms, or will enhance human consciousness if understood from a psycho-spiritual perspective.”

At the IASD conference, Duran spoke of how in some indigenous tribes, taking the life of another indebted the warrior to the deceased soldier’s family for his lifetime. Often those who have taken a life dream of the deceased, both those whose lives they may have directly or indirectly taken, and they also dream of compatriots who lost their lives in battle. These dreams are a constant reminder that keeps their suffering alive, sometimes for decades, unless some kind of healing takes place. There is an understanding that while different rules apply during wartime, there is a need for balance and restitution upon returning to peace, and that these acts of atonement are as important for the agressor as they are for the victims of violence.

Practically speaking, this means that a soldier who has taken a life must make amends in some way to the person or the family and community whose life they have taken. This can be done through offerings, direct service, ceremony, therapy and ultimately, self-forgiveness. Duran said the pull toward suicide in such cases is may also be seen as an attempt to restore balance (a life for a life) but one that merely doubles down on losses. He calls suicide a desire for transformation, an important call, though not one to be taken literally.

In many indigenous traditions, suicide is a spirit that calls for transformation, which can lead to a spiritual rebirth, and a new life. Duran believes Western paradigms misinterpret this as suicidal ideation, as an impulse to take one’s own life in the physical realm. He said it’s crucial to not only treat PTSD symptoms, but also the deep moral injury that can lead to a desire for death. “A larger issue of soul separation is what is calling for a transforming event, such as we encounter in death. Therapeutic ceremony that allows for soul restoration is a must.”

 

Moral injury leads to higher suicide risk

A recent study (Battles et al., 2021) confirmed that suicide risk is higher among those veterans who have suffered a moral injury, which has symptoms in common with PTSD, but also a unique and complex presentation. The researchers found that those with strong guilt and shame, as well as comorbid psychiatric conditions, carried the highest suicide risk. The symptom picture differs from the flashbacks, nightmares and hypervigilance associated with PTSD. Moral injury and the shame associated with it bring depression, anxiety, loss of trust, and social alienation. The researchers concluded that while there is overlap between moral injury and PTSD, there are distinctive differences that need to be considered in treatment and prevention of suicide.

Another recent article addressing the impact of war on veterans found that the way they dream has unique characteristics. Miller, Ross and Harb (2021) studied the dreams of 54 veterans with PTSD and found that more than half of them were experiencing lucid nightmares of the most challenging variety. Participants were aware they were dreaming, but this did not lend them greater control over these distressing dreams. Instead, they reported feeling stuck, anxious and unable to wake themselves up from their distressing dreams.

Normally, lucid dreaming is associated with feelings of greater well-being, autonomy, assertiveness and confidence, but not in these cases. Although lucid dreaming has been studied as a treatment for traumatic nightmares, in these cases, the notion of taking control and achieving mastery over the dream content is not viewed as a promising pathway. The authors suggest that helping veterans who suffer from lucid nightmares to learn to distinguish these dreams from reality might be a useful focus of treatment.

In this and other recent studies, it is apparent that the treatment of veterans suffering from past-traumatic and/or moral injury is a complex business, and one that deserves further attention and study, especially because it may help reduce the high prevalence of suicide in this clinical population. It’s important for clinicians to understand that moral injury, and lucid nightmares are among the complex challenges in working with veterans, but they are treatable. There is hope.

If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable. Check out our Short Focused Course on Nightmare Treatment using THIS LINK.

 

References

Battles, A. R., Jinkerson, J., Kelley, M. L., & Mason, R. A. (2021). Structural examination of moral injury and PTSD and their associations with suicidal behavior among combat veterans. Journal of Community Engagement and Scholarship, 13(4).

Duran, E. (2019). Healing the soul wound: Trauma-informed counseling for indigenous communities. New York, NY: Teachers College Press, Columbia University.

Miller, K. E., Ross, R. J., & Harb, G. C. (2021). Lucid Dreams in Veterans with Posttraumatic Stress Disorder Include Nightmares. Dreaming, 31(2), 117-127.

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Nightmare-Suicide Link Extends to Adolescents

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Read on to find out how you can help!

If you know or work with a deeply troubled teen, you might consider asking them about their dreams. If they report frequent disturbing dreams or nightmares, they are at a greater risk for suicide. The link between adult suicide and nightmare frequency has been well established, and a new study extends this correlation to young adolescents. The good news is that nightmares are treatable, and some very simple steps can make a meaningful difference.

In a recent study based in Montreal, Canada, Aline Gauchat and colleagues studied both the dreams and suicidal ideation of 170 children when they were 12 and again at age 13. Disturbed dreaming tends to lessen with age and did so in this sample. At the same time, the rate of suicidal ideation increased, and analysis of the data showed that the adolsecents who had suicidal ideation had significantly more disturbing and recurring dreams.

This is another piece of mounting evidence that when working with those with a potential risk of suicide (for example those with depression, borderline personality or a history of complex trauma) you should ask about nightmares as part of the screening process.

 

Why we should ask about nightmares

Dr. Michael Nadorff, who has conducted several studies linking nightmares and suicide, noted with dismay that in the past 50 years, we have not become any better at predicting suicide. Paying attention to dreams, in particular the frequency of disturbing dreams and nightmares, is one way to help determine who is most at risk.

The other important thing to note with respect to the nightmare-suicide link is that effective nightmare treatments are available. In his talk on nightmares at the recent (June, 2021) conference for the International Association for the Study of Dreams, Nadorff noted that of those with dangerously troubling dreams, only one person in ten might report this to a mental health professional. There are a couple of reasons for this: those with frequent nightmares don’t always realize that such dreaming is not typical. And very few people are aware that nightmares can be treated. People also hesitate to talk about their nightmares for fear of being judged for the dark images that haunt their sleep.

However, talking about nightmares, and getting treatment can have positive effects that extend beyond the simple reduction in the frequency and distress caused by disturbing dreams. In general, symptoms of depression and trauma dissipate, and although this has not been specifically studied, it is fair to suggest the risk of suicide drops significantly as well.

Instilling Hope

When asked what he thought made nightmare sufferers more likely to consider taking their own life, Nadorff said he thinks a lack of hope is a major contributing factor. For frequent nightmare sufferers, even sleep is not a refuge from their tortured thoughts. Those contemplating suicide report deep loneliness and a sense that they are a burden to those closest to them. He suggests intensive support for those whose risk of suicude is high, stressing that the periods of high risk are time-limited.

Treating the nightmares of those contemplating suicide is also something Nadorff recommends, though this idea has not taken hold very widely, at least not yet. But Imagery Rehearsal Therapy (IRT), lucid dreaming, and several other nightmare treatment protocols demonstrate that it can be fairly quick and easy to reduce nightmares and their related distress. In my survey of the nightmare literature, I have found that virtually all methods researchers tried seemed to help, and adverse effects seemed absent.

The common denominators in nightmare treatment include instilling hope by teaching those with nightmares that they are treatable and it is entirely possible to change their dream life for the better. The other key elements of treatment are to write, rescript or re-imagine a new ending to their nightmare, ideally one that gives them a sense of mastery over the challenge presented in their dreams. They can, for example, develop a superpower that enables them to escape or overpower their attacker. In my experience, the more richly imagined this new dream ending is, the more power it has to change subsequent dreams. If it sounds too simple, don’t be fooled… it can really be that easy to make a meaningful difference, possibly even save a life.

 

Some further resources:

Help for nightmare sufferers (free PDF) CLICK HERE

A short focused course on nightmare treatment for clinicians CLICK HERE

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

 

References

Gauchat, A., Zadra, A., El Hourani, M., Parent, S., Renaud, J., Tremblay, R. E., and Seguin, J. R. (2021). Association Between Recurrent Dreams, Disturbing Dreams, and Suicidal Ideation in Adolescents. Dreaming 31(1), 32-43.

Nadorff, M. (2021). Invited talk for the International Association for the Study of Dreams (IASD) Online Conference, June 13-17, 2021.

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REM Rebound: Managing intensification of dreaming when sleep deprivation or substance use stops

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When you end a period of sleep deprivation or substance use, your dreams return, sometimes with a vengeance. Dr. Leslie Ellis explains how to understand and manage REM rebound.

While the global pandemic has been identified as a big factor in the recent increase and intensification of dreaming, a phenomenon called REM rebound may be the mechanism at work in some cases. REM sleep is so important that following a period of REM deprivation, our bodies will automatically make up for what it has missed. REM rebound is characterised by intense dreaming and a structural shift in the normal sleep cycle.

Sleep rhythm will return to normal once we have made up our REM sleep debt. This can take days or weeks depending on why, how long and how severely the sleep cycle has been disrupted. There is much in the literature about how to manage sleep problems associated with REM rebound, but very little in the way of help with what to do about all those troublesome dreams. Read on for some simple suggestions from a clinical dream and nightmare expert.

 

What is REM rebound?

First, we need a basic understanding of rapid-eye-movement (REM) sleep. This is the sleep stage most associated with dreaming. In a typical night, we have 4-5 REM sleep periods that gradually increase in length over the course of the night. In total, we spend about 90 minutes or more in REM sleep during a typical 8-hour night of sleep, with most of our REM concentrated toward morning. If we become deprived of REM, our bodies will drop into REM immediately upon falling asleep instead of moving through the progressively-deepening cycles of non-REM sleep that typically start our night. This is REM rebound, a natural increase in REM to make up for what was missed, often due to sleep deprivation or the kind of stress that leads to restless, broken sleep.

There is considerable research to support the notion that REM sleep and dreaming help to regulate emotional reactivity and to reframe negative experiences. REM sleep affects hormonal balance and sleep homeostasis. To return to the normal, restorative sleep patterns so important to all aspects of our health, we may need to go through a period of intense dreaming to allow our sleep rhythm to reset itself. My suggestion is to befriend this process. A first step is to understand that even our most frightening nightmares are trying to help us by balancing our emotional state and taking the charge out of challenging past and current life situations. We can work with them, not against them. More on this later.

 

Substance Use and REM Rebound

The most common cause of REM rebound is sleep deprivation, especially very early awakening that cuts off the second half of our sleep. REM rebound also happens when a person stops taking a substance that suppresses REM sleep. These include many commonly-used substances like antidepressants, alcohol, cannabis and benzodiazepines. Paradoxically, many of these substances are used to promote sleep – and while they can help you fall asleep, they disrupt normal sleep architecture, ultimately making the situation worse. (Newer sleep aids like zolpidem do not cause this problem.)

Sleep is critical to our emotional and physical health. Insufficient or poor-quality sleep is associated with poor emotional regulation, diminished ability to consolidate memory, a higher risk of psychiatric illnesses (depression, anxiety, PTSD), obesity, heart disease and stroke as well as increased risk of workplace and vehicle accidents. Clearly, getting a good night’s sleep is critical to all aspects of our health. Getting sufficient REM is intrinsic to this process.

The best way to overcome REM rebound is simple, yet it can also be a challenge for those with chronic difficulty sleeping well. You simply need to get enough good-quality sleep to make up the REM that your body requires. There are plenty of resources available on good sleep hygiene: things like a calming bedtime routine, limiting screen time, caffeine and alcohol before bed, and getting enough exercise are well documented and can help.

However, for some people, the intensely disturbing flood of dream imagery following the cessation of substance use can make it tempting to go back to taking the antidepressant medication or addictive substance they want to stop using. For those in this category, part of the answer is to befriend your dreams, especially those that have returned with great intensity following a period of silence. If you have intense, frequent and disturbing nightmares during the REM rebound period, making friends with these dreams may seem like an impossible task, but it’s not. Few people realize that nightmares are both treatable, and in many ways, also helpful in the emotional recovery process.

 

Changing Your Relationship With Your Dreams

Dreams and nightmares have been shown to temper emotional intensity. Studies suggest that when we dream about a disturbing scenario, we generally feel better about it than we did before. The big problem with nightmares is that they can be so intense, they wake the dreamer up, so they disrupt sleep rather than helping. A simple solution is to imagine the dream forward; just let it continue from where it left off until you get to a place that feels like more of a resolution. It doesn’t even have to be a triumphant solution, just one that carries the dream forward.

In my experience, this simple process can effectively stop or change a nightmare immediately. It can also take a few tries, and in some cases might require professional help. If you have PTSD or a history of trauma, a professional trained in working with nightmares can make the difference. There are many studies on a version of this method called Imagery Rehearsal Therapy (IRT) that show it often helps, and when it doesn’t, it causes no adverse effects. In other words, it’s worth a try.

In general, getting to know more about your dream world and what it’s trying to tell you will set you up for a more positive relationship with your dreams. I have written extensively about this, and will post a list of resources in the references below. My main message, having worked for decades with the dreams of those recovering from trauma and addiction, is that your dreams are trying to help you, not hurt you. Dream lovers welcome the flood of nocturnal images that characterize a REM rebound. If you are someone who has stopped the use of a REM-suppressant substance, for whatever reason, be prepared for the dreams that will come to you, and find a way to welcome them. Also know that the condition is temporary and if you can stay the course, your normal sleep rhythm will return.

 

Dr. Leslie Ellis is the author of A Clinician’s Guide to Dream Therapy, and an expert in dreamwork and nightmare treatment. Her web site (www.drleslieellis.com) contains many resources about how to work with dreams and nightmares.

 

Resources:

There Are No Bad Dreams – a Ted-like talk about nightmares.

Nightmare relief, free PDF: What you can do about nightmares

For clinicians: A Short Focused Course on Nightmare Treatment

Live Oct. 13 (and recorded) Live workshop on Nightmares and the Nervous System

Blog post: Whether and how to work with traumatic nightmares

Blog post: Whether and how to work with traumatic nightmares

 

Selected references for this article:

Ellis, L. (2019). A clinician’s guide to dream therapy: Implementing simple and effective dreamwork. New York: Routledge.

Feriante J, Singh S. (2020). REM Rebound Effect. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560713/

Krakow, B. and Zadra, A. (2006). Clinical management of chronic nightmares: Imagery Rehearsal Therapy. Behavioural Sleep Medicine, 4(1), 45-70.

 

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How to Become an Exquisite Listener

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Listening is perhaps the greatest gift we can give to each other, especially in this time of social distancing, yet few people really understand how to listen. Here are four essential tips from someone who makes her living listening.

In this time of physical distancing, it is more important than ever to listen well to each other. Feeling heard is a way of feeling connected. In a brief video, Stephen Porges explains how our ability to listen has been eroded by technology, in particular by the fact that much of our communication is no longer in real time. He says our nervous system is designed for synchronous communication: for getting an immediate response to what we say. We have “the expectancy of a reciprocal relationship” in interactions, and when that doesn’t happen, we suddenly feel less safe in our bodies.

Porges suggests that to counteract the detrimental effects on our nervous system of both technology and social distancing, we need to relearn how to be excellent listeners. We need to make it very clear that we are paying attention and that we care. If we do this, our online interactions can provide the kind of support we usually get in closer contact with each other. The following are my suggestions about how to take Porges’ advice and to listen exquisitely.

Seek to understand fully

Too often we jump into another person’s narrative with advice, observations, or worse: examples of our own similar experiences. Most of us tend to do this before we truly understand and absorb what the person is trying to communicate. To become an exquisite listener, tune your ear to the nuances of their message. Take what they are saying down into your body very patiently. Seek to listen only, rather than taking up part of your mental energy formulating a response. If you do this, they will feel you are really with them, and it will infuse what they are saying with more energy and enthusiasm. It will be easy to just listen.

Never interrupt… with one exception

It may seem like common courtesy to allow the person speaking to have the floor until they are clearly finished what they want to say, but in fact, we are prone to interrupting each other. Studies have found that men are significantly more likely to intrusively interrupt women speaking in mixed-gender settings. But the research also found that we all do it, either by chiming in before the other is finished, a sort of ‘joining-in’ interruption, or by intrusively challenging the speaker or taking over the floor. Either way, if you want to be an exquisite listener don’t do it!

There is only one exception to the rule of no interruptions: when you don’t hear or understand what the speaker is saying and you need to seek clarification. Even here, make sure you hear them out first because they may be getting to the part you need to know to understand, and your well-intentioned query can interrupt their flow. Wait for a pause or natural stopping place and then say something like: ‘Can we go back to this point, because I’m not quite sure I understood you fully…”

Give advice or commentary only when asked

As with interruption, abstaining from offering solutions often splits along gender lines. Men tend to listen with an ear to problem-solving and so are more likely want to offer solutions. But we all do this at times. As therapists, we are often expected to offer advice and solutions to our clients. But excellent listeners offer advice only when specifically asked, and then do so only sparingly.

As a client-centered therapist, I believe my client is the expert in their own life situation and my job is to listen well enough to help them arrive at their own answers. I think this is generally true — when we offer unsolicited advice we are implying that we know more about their situation than they do, and this can leave them feeling unheard, possibly even as though you have insulted their own intelligence and capacity to work things out for themselves.

Communicate understanding and empathy

So what can you say if you want to be an exquisite listener?

The first most helpful thing is to communicate your understanding of them. When you have invested the time and full attention to hear them out, saying back what you understand helps them to feel truly heard. This is not a mere parroting of their words, which can feel mechanical, but rather a digested response. It may be only a few words you offer, but choose those that show you truly get what they have said.

It takes discipline to be an excellent listener. You have to resist the urge to add your own ideas, experiences and solutions. If you do feel compelled to add something, add compassion. Search inside yourself for something genuinely empathic to offer, something that communicates the message: I can really see how, given all of that, you would feel this way. Say this even if you happen to disagree with their position and think they should try another tack.

Interestingly, when someone feels fully heard and validated, they are then in more of a position to consider alternatives. If you challenge them, they may well become more entrenched in their position. But full acceptance is a powerful catalyst to further steps forward. However, as philosopher Eugene Gendlin once said, these steps will come from inside the person or not at all. If we offer something of our own before the time is ripe, the person will not only feel unheard, but will resist the idea.

Passive as it may seem to you at first, exquisite listening is not always easy; it’s a skill that takes discipline. And it is a gift to all, especially in times like these. Being fully heard allows the speaker to rest in their own experience and find the right next step from inside of themselves.

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Jungian dreamwork basics from John van Eenwyck at the Jung Platform Summit

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Jung wrote vast amounts of material about dreams, so much that to approach the topic can be intimidating. In the first lecture for the free dream summit now taking place on The Jung Platform, John van Eenwyck pares this enormous topic down to a few helpful ideas about how to work with your dreams.

The first thing van Eenwyck says is that we don’t really know what dreams are. This echoes Jung’s idea that we should approach each dream as if it were a totally unknown object. In particular, we cannot assume we know anything about the meaning of the dream images of someone else. That said, Jung saw dreams as complementing waking consciousness by presenting the opposite of our day-world view. For example, a priest who lives an exemplary life dreams of dark, sinful behaviors at night. Our dreams often pick up on our shadow, or our unlived life.

To engage with your dreams, you need to record not only your dreams, but also their context. We all know that keeping a dream journal involves writing down our dreams, ideally as quickly as possible after dreaming them, and in as much detail as you can recall, because otherwise dreams often slip away. Van Eewyck also suggests that before going to sleep, we jot down a few lines about the main events or what occupied our thoughts during that day. This way, we can relate the dream content to the events of the previous day, the so-called ‘day residue.’

He also suggests we avoid editing our dream material. Write down everything that you can about your dreams upon waking – from having no dreams that you can recall, to recording vague sensations or emotions, and from small dream snippets all the way to epic dream stories. When we do this over time, we build an archive of our dream life, something we can refer back to.

To work with another’s dream, we might first look at the setting: who or what is in the dream, and where does the dream take place? Then we can ask into the dreamer’s associations; what the dream elements mean to the dreamer is far more relevant than what we, as the dreamwork, may think a dream image means. After this, we can engage in amplification of the dream, looking at what stories and myths might relate to the dream, and then checking with the dreamer to see if anything resonates for them.

Lastly, the biggest takeaway for van Eenwyck is Jung’s suggestion that we dream the dream onward. This is particularly true for nightmares because by definition, we wake from them in the middle of the action, before the dream has reached a resolution. He provides a poignant example of Ruby, a client who had severe Lupus and was given six months to live. In her frequent nightmares of a pursuer who planned to rape and kill her, Ruby would work with van Eenwyck to dream the dream on to a better place. The last time she had this dream, she turned toward her would-be killer and it was a 9-year-old boy looking for help to find the way home. She did help the boy, and not only did the nightmares cease, but she also experienced a lifting of the severity of the disease, and lived for many years beyond what her doctors predicted.

Was this spontaneous remission due to the dreamwork? Or did the dream reflect the unexpected turn for the better in her health? Like so many things about dreams, we can’t know for sure. Van Eenwyck concludes that we don’t waste too much energy looking for definitive ideas about dreams, but instead to enjoy them. He concludes, “The essence of dream analysis is play.”

Join me and 11 other dreamworkers Jan. 14-17 for a free dream summit exploring the fascinating world of dreaming. Look for my talk on why and how to use dreams in clinical practice on Jan. 16 at 11am PDT.