Category: Nightmares

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Dreaming in Times of Collective Crisis: A nocturnal perspective on Ukraine

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Recently I dreamt I was standing on a rocky, mountainous ridge, the stone an iron colour, like dust mixed with blood. I am looking for a way down, and all the options seem treacherous. Suddenly, the ground begins to split under my feet, a massive slice of it neatly dropping away. It feels as if this has destabilized everything around me, as if the earth’s crust has suddenly lost its integrity. I am left in a state of expectant waiting-for-disaster and not sure what form this will take. To me this dream clearly speaks to the devastation I feel as I watch, with the rest of the world, as the horrifying events of the Russian invasion of Ukraine unfold.

Like the recent global coronavirus pandemic, the war in Ukraine is an event that affects us all. It has destabilized the world and divided countries along ideological lines, which has the frightening potential of leading to a much larger war. The pandemic clearly infiltrated the world’s dreams, increasing dream recall and disturbed dreaming, and introducing themes related to health, loss of freedom, invisible threats and death. A number of studies have documented this global phenomenon, lending support for the continuity hypothesis that suggests that waking-life concerns find their way into our dreams. The same holds true for the way war now unfolding is infiltrating our collective dreaming.

In a recent and poignant session with one of my dream classes, I wanted to take a moment to acknowledge the harrowing events in Ukraine. I shared my dream and the personal nature of the war for me. Half my ancestry is a mix of Ukrainian, Russian and Polish. The borders have changed so much in the areas where my mother’s family originated that the same area was at times Russian, Ukrainian or Polish. The epicenter, according to my ’23 and Me’ ancestry test, is at Lviv, now part of Ukraine, part of the area that is being systematically reduced to rubble.

My dream of the ground splitting under my feet feels like a direct response and an apt metaphor for what is happening in Ukraine. This war feels very close to home, destabilizing and so much bigger than me. Others in the dream group, and in other dream circles I tend, have been reporting similar themes: dreams of invasion, of violence and displacement.

One poignant example was a recent dream offered by Theresa, her in-laws having immigrated over 50 years ago from what is now the Ukraine, Germans fleeing from the Russians. Recounting the dream, she said, “I am at my mother’s house. Looking out from the second-floor deck (of my current home), I see the new neighbour with his teenage sons looking towards me. They have torn down the fence and stripped my mother’s backyard of all its’ bushes and flowers. One tree remains, an apple, with only the trunk left standing. Now I find myself in my mother’s basement, the neighbour there with his boys, though younger in age. The room is wild, toys spread chaotically everywhere. I ask the one boy to clean up his mess and he defiantly refuses. I go upstairs to ask his father, the neighbour, and my husband, for help. By the time we return to the room, the toys are cleaned up and the other children confirm the young defiant one has helped…”

Many in the group could relate to the themes of invasion, destruction and utter disrespect of boundaries in the dream. There was a collective sense of grief, sadness and frustration expressed. However, the dreamer is given the last word in this dream process and Theresa said she ultimately saw this dream as one of reconciliation, the coming together of warring parts that have entered the foundation of her mother’s home; an invitation to have all take part in the commitment to a better way.

Recounting the dream brought deep and surprising emotion for the dreamer. Theresa said that her dream invited process at the collective as well as personal level, speaking to the situation in the Ukraine, and her life. She recognized the dream was showing her the power of our own ‘sacred motherland’ and at another level, the strength of the archetypal divine feminine to stand loving and firm while holding chaos and destruction. She felt the dream was hopeful in that her call for help was answered by the two adult men, as well as the children. One apple tree was left standing, the potential for regrowth still present. (The biblical symbolism of the garden of Eden is not lost on us.)

When I had my dream of the ground splitting, or when someone brings a dream of invasion and destruction, I wonder, as I am wont to ask, what is helpful about such dreams?

For the dream groups I am hosting, discussing dreams in times of crisis gives us a venue to feel and express our concerns and the deep emotion that has been stimulated by world events. We can hold each other in our grief and sorrow. Many of us have been given an image or a metaphor for our deep unexpressed feelings. This does not solve the larger problems, but it does make us feel less alone with them and it prompts action, in whatever ways we can offer help.

That world events can infiltrate our dreams makes sense because intense emotion is the fodder of dreams. World crises are changing our dreams collectively, demonstrating how we are all in this together. Information travels fast, and no longer do massive humanitarian crises take place in secret. My hope is the increasingly collective nature of world events can begin to sow the seeds of peace.

Near the close of the dream group, one member, through her tears, spoke in response to Theresa’ dream, “The devastation image was so immediate and resonant of Ukraine, and then Theresa brought such compassion to it. If we are going to dream our mutual dream of the human race forward, this is what will lead us.”

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Nightmares and the Nervous System: A new way to understand and treat nightmares

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In the world of trauma therapy, a paradigm shift has been taking place over the past decade or so, a marked shift toward embodied and somatic approaches to the understanding and healing of trauma. The polyvagal theory by Dr. Stephen Porges has led clinicians to consider that much of what was previously viewed as pathological behaviour can be seen as adaptive responses that our client’s autonomic nervous systems (ANS) have initiated as a means of protection and survival. This hopeful and non-shaming approach has changed the way trauma therapy is practiced for so many… yet the paradigm shift has not found its way into the treatment of nightmares. I feel that it’s high time for this to change because nightmares deserve clinical attention. They are a cardinal symptom of post-traumatic stress injury, and associated with complex trauma, anxiety, depression and many other mental health challenges. They have been strongly correlated with increased suicide risk.

I have been doing my best to help more clinical attention to nightmares and opportunities for training. I have spent the past several years developing a theory and treatment protocol for nightmares that takes the polyvagal theory into account. This work is the basis of a major article (now under review) and two online courses on nightmares, one for clinicians and one for the general public. I am consistently sending the message that nightmares are urgent messages from the body, attempts at trauma recovery and at getting the dreamer’s attention so they can attend to underlying sense of threat that haunts their nights. Nightmares are treatable, yet so often they are not treated. And in the   most serious cases, where they may lead to greater suicide risk, I believe treatment is imperative.

 

Nightmares reflect a nervous system that doesn’t feel safe

One of the most freeing aspects of Porges’ theory is the idea of ‘neuroception’, which is the internal sensing process which happens automatically, outside of conscious awareness, as our bodies pick up cues of threat and safety from the environment and react accordingly. The theory states that our autonomic responses happen in a specific order – first with activation to fight or flee from danger, and second with immobility or shutdown when fight or flight are not possible or advisable. Shutdown in the face of an overpowering aggressor may in fact be the wisest choice, though it is completely out of conscious control. Knowing this has helped rape survivors, for example, understand why they went limp and didn’t fight back, an action their own body deemed would put them in even greater danger. This knowledge reduces their sense of shame.

 

Nightmare content reflects the autonomic nervous system

Something interesting I noticed in working with nightmares over time is that the content of these dreams often reflects the various states ascribed to nervous system responses. The vast majority of fear-based nightmares depict scenes of being chased or running away (flight), of being faced with agression (fight) or of a sense of frozen hopelessness and inability to move (immobility). It is as though our dream content is describing our autonomic state. The beauty of this is that it is not static, but can shift and change in response to cues from the environment.

Porges has stated, quite simply, that when in comes to trauma and resulting ANS reactions, “safety is the treatment.” I have found that with frightening dreams, if you can instil a sense of safety in the dreamer, either within the dream itself, or after that fact in working with the dream material, it can shift even long-term recurrent nightmares, sometimes permanently. Too often I have seen that nightmare sufferers feel like victims of the terrifying dreams, thinking there is nothing they can do, making them fear sleep itself, which is ideally a balm and a time for deep rest and recovery.

 

Not all nightmares are the same

One thing that the polyvagal theory has helped me to understand is that there are two distinct responses to trauma and adversity – one is highly activated and the other is more dissociative. The pathway to safety and recovery from these two states is different, yet most nightmare treatments are applied as if they are all the same. When a person’s body reflects collapse or immobility, what the polyvagal theory states is that they are very far from being able to engage with someone who is trying to soothe or help them because they have turned inward and their social engagement system is shut down. Porges says the path back from this state is longer and more complicated and needs to pass back through the activated state most of us associate with trauma.

In either case, instilling a sense of safety and then of connection will help shift the dreamer’s state, and often, the memory of this stays with them when they next encounter the fear response within their dreams. This is why the popular nightmare treatment method of ‘rescripting’ or rewriting the content of one’s dreams can be so powerful. When we revise our dream narratives, we can add empowerment, help from others, a new way of seeing the situation that renders it less threatening… or anything that feels right to the dreamer.

In my work with dreams and nightmares, I always ask the dreamer to find and then embody any aspects of the dream they find helpful – and to imagine the dream forward to include such elements if the dream itself contains no such sources of support. When they experience a sense of power, of safety and of company in the face of their haunting dreams, these dreamers often hold on to it, and the potential for a helpful shift is available to them next time they have a similar dream. This brings hope and change to places that felt frozen in place, the beginning of a new and more empowering relationship to one’s embodied dreams.

 

Do you know someone who suffers from frequent nightmares? Or are you a parent concerned about the frequency and intensity of your child’s bad dreams?
Learn why treating nightmares is both essential and surprisingly simple in these two online course about nightmare relief.
Nightmare Treatment Imperative – The complete course for Clinicians
Nightmare Relief for Everyone –  A little course designed to help everyone
Learn how to treat nightmares with evidence-based methods!

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Treating Trauma and Addiction with the Felt Sense Polyvagal Model: A Bottom-Up Approach

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A timely and compassionate book on treating trauma and addiction using the Felt Sense Polyvagal Model.

Just at a time when the wider world is waking up to a more compassionate and inclusive way of understanding trauma and addiction, a timely book that addresses these issues in personal, historical, embodied and practical ways has arrived. In Treating Trauma and Addiction with the Felt Sense Polyvagal Model: A Bottom-Up Approach (Routledge, 2021), author and psychotherapist Jan Winhall both demystifies and depathologizes addiction. She does so by demonstrating in theory and with compelling case studies how addictive behaviours are in fact resourceful attempts to regulate a body that has been thrown out of homeostatic balance by traumatic experience.

Winhall’s new book incorporates both focusing and the polyvagal theory to create a treatment model for that is both effective and humane. It’s a model to help those afflicted with addictions and other effects of trauma understand their own physiological and emotional responses, and begin to take steps toward change that are both self-compassionate and doable.

Winhall explains how addiction is a propeller of neurophysiological state change, and in doing so, she solves the mystery of addictive behavior that puzzled her so much as a young therapist. She begins her book with the compelling story of her first women’s group and the mystery of their deeply self-harming behaviors. At the time, she simply couldn’t understand why this fascinating group of young incest survivors would engage in such self-destructive acts. Rejecting the idea that they were simply damaged, broken and ‘borderline’, Winhall went on a decades-long hunt for a more compassionate understanding of how to help these women heal.

A consistent thread through the book is Jan’s story of her own development as a trauma therapist, and it illustrates the evolution of ideas about the etiology and treatment of trauma over the past 40 years. Early influences include Bass and Davis’ The Courage to Heal, and Judith Herman’s classic, Trauma and Recovery. Add to this mix a deep understanding of Eugene Gendlin’s focusing, which brings a way to listen to the body in a way that assumes it knows the way forward. Stir in a healthy grounding in Dan Siegel’s interpersonal neurobiology, Bowlby’s attachment theory, the compassionate views of Gabor Mate, the relational wisdom of Harville Hendrix and Helen LaKelly Hunt, and finally, the updated understanding of the nervous system’s response to threat and connection as proposed in Stephen Porges’ polyvagal theory.

When you combine all of these embodied, compassionate approaches to working with trauma and addiction, what emerges is a model that stands in stark contrast to the medicalized version which pathologizes those who have already suffered so greatly. As Jan so aptly demonstrates, those who have suffered trauma and subsequently engage in a range of addictive behaviours are not broken, but in fact, doing their best to manage their pain and overwhelming emotions in the ways that are most available to them. It reframes their stories from tales of illness to journeys of triumph and liberation.

Winhall’s definition of addiction is a simple and non-judgmental one: “It helps you in the short term, hurts you in the long term, and you can’t stop doing it.” However, the historic view of addictions is not so kind. Winhall leads the reader through a history lesson that shows how the war on drugs, and the controversial evolution of the ‘disease model’ of addiction has led to racist and pathologizing ways of viewing addictive behaviour. It has also prompted many resilient trauma survivors to view their own attempts at self-regulation as shameful and bad, an attitude that hampers their recovery.

The Felt Sense Polyvagal Model

Over her many years of working with those who have suffered from trauma, and with a naturally compassionate and inquiring approach, Winhall has developed a model that makes sense of addictive responses that alleviates blame and shame, and replaces it with ways that clients can make sense of their own shifting states. Through a clear, graphic diagram of the physiological states described by Porges’ polyvagal theory, and guidance on how to map one’s unique pattern of experiences onto this chart, clients can begin the make sense of their own behaviours. They are then offering tools to help them decide how to take systematic and doable steps toward changing those behaviours that are most hurtful in the long term into more healthful ways of managing intense states.

Winhall has included both a detailed model for clinicians and a simplified one for clients in the book as a visual aid for understanding patterns of behaviour that can readily be reframed from addictive to adaptive. In addition, she offers a detailed Embodied Assessment and Treatment Tool (EATT) and a comprehensive list of focusing-oriented strategies that can be tailored to particular clients and their unique challenges. There is also a version for couples, and a lovely case study of how these tools led a couple struggling with the impact of childhood sexual abuse toward deeper connection, understanding and mutual compassion in the face of the painful experience of sex addiction.

Focusing and Thinking at the Edge

Focusing, developed by Eugene Gendlin, is another thread that runs through this book, and is a foundational practice for Winhall. She takes us back to her first meeting with ‘Gene’, as he is affectionately called, and the ways in which his conception of the felt sense brought all of the pieces of the puzzle together for her. She writes, “The felt sense contains the whole of our experiencing, including content and process, thinking and feeling: the sweet spot of integration.”

Winhall’s book not only contains a primer on focusing concepts and their rich underlying philosophy, but also practical examples and many places in the book that invite the reader to pause, check inside, and engage in the material in a focusing-oriented way. In this way, the book is an example of what it describes, a personal journey into the heart of addiction and trauma that invites an embodied response to the material, not just an intellectual one.

In travelling this journey that Winhall takes you on, weaving historical and factual information with personal vignettes, and poignant case studies told with the mastery of a novelist, there is another enduring theme that emerges: one of consilience. What we see, over the course of this immersive journey, is how all of these ideas are related, how they are often different ways of saying the same thing. This makes sense: we are all human beings, sharing the same basic emotions and responses, and Winhall helps us see how we are truly all in this together. Addiction and responses to trauma are not something ‘out there’ that only ill and damaged people engage in. Rather, we are all ‘shaky beings’ (to use Gendlin’s phrase) that are doing our best to self-regulate, to engage in life, and if needed, to liberate ourselves from patterns of behaviour that were brilliant solutions at the time, and may need updating.

The FSPM teaches us all how to identify our autonomic states, to feel into them in the moment and to understand what drives them. It teaches us how to deepen into our own experience and to subsequently guide others into this inner terrain in ways that feel safe and respectful. It moves us from a medical model to one of both self and co-regulation, from framing responses to trauma as acts of triumph and courage rather than freakish acts of self destruction.

This book reads like a story that begins and ends with Winhall’s first women’s group, and her lifelong drive to understand and help these women heal. She offers the example of Bridgette, who was convinced she was a ‘freak’ because of the times she would awaken from a dissociated state to find she had taken a razor to her own vagina. Winhall speaks of how she knew, even before she had fully articulated her model, to ground and connect Bridgette and to ‘validate and celebrate’ her body’s response to trauma, to see it as a way to release the pain and shift away from an unbearable state.

Jan writes, “As I explain this new way of understanding, her face opens. She looks around and see the women in the group riveted by her journey. It is their journey too. Looking incredulous, her jaw drops, and she lights up. Bridgette moves from feeling like a disordered person to a hero who made it through living hell. It is a moment of liberation, a profound shift that changes everything. These moments of liberation, arising out of a system that shames and pathologizes, are the heart of transformational healing. I pause here inside. These are the moments that I live for in the work.”

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Riding the Waves

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A shift in dreaming patterns from the first to second wave of the COVID-19 pandemic

A year and a half ago, as the full scope of the pandemic that was descending on us became apparent, there was a global increase in severe stress, worry, fear and uncertainty. Reports of heightened dream recall and dream vividness were also on the rise, with many experiencing nightmare-like depictions of their greatest pandemic fears realized. This was a time of great upheaval and dysphoria, or, as Harvard professor and dream researcher Dierdre Barrett put it, “an extraordinary time in the history of dreaming.” Global dreaming trends can give us crucial insight not only into our collective mental state, but into how times of crises are reflected in our dream lives.

In Wuhan, a study of 100 nurses working on the front lines found almost half were experiencing nightmares (Tu et al., 2020) and an online survey of 811 individuals reporting dream content found 55% had pandemic-related dream content (Pesonen et al., 2020). As the first wave of the pandemic subsided, dream reports began to decrease. Many reported a “return to baseline” in both dream recall and emotionality (Scarpelli et al., 2021). But we all know this isn’t where the story ends.

Enter the delta variant, causing more infections and spreading more rapidly than its predecessor, plunging many countries into a second wave. So what happened to our collective dream lives during the second wave? Researchers are now sharing their answers.

In the spring of 2020, Scarpelli and colleagues released a web survey to “collect socio-demographic information, psychological and sleep measures, and dream variables” from participants in Italy. Then the second wave hit Italy in October of 2020, giving Scarpelli and colleagues the unique ability to conduct a longitudinal within-subjects study of oneiric activity in different stages of the pandemic.

The researchers released a second survey to the participants of the previous survey, designed to investigate dream changes during the second wave compared to the first wave of the pandemic, and 611 participants responded. They asked about dream recall frequency, nightmare frequency, lucid dream frequency, emotional intensity and nightmare distress. Interestingly, all variables, both quantitative and subjective, were lower in the second wave, yet the emotional tone of the dream content was more negative. Essentially, people are remembering their dreams less, apparently dreaming less, yet the dreams they do have are more negatively toned.

The Scarpelli study was not the only one that who found this. Conte and colleagues (2021) showed that “reported dream emotional tone became significantly more negative both in total lockdown and partial lockdown (second wave) compared to previous periods.” In addition, they found that waking mood was much more negative and fearful during the second wave. Since pandemic dreaming has largely been supporting the ‘continuity hypothesis’ that our dreams reflect waking life concerns, this suggests an over dip in mood and increase in fear which may reflect the fact that by now, most of us believed we would have put COVID-19 behind us. Instead, it seems increasingly unpredictable and lasting, and many people are losing patience and hope.

Each wave in each country hits the residents differently, and everybody rides the waves in their own fashion. Yet, after the devastating effects of the first wave in Italy, it is not difficult to imagine how facing a second wave could elicit negatively toned dreams in Italian residents. A German study by Moradian and colleagues found that during the second wave, participants had more depressive symptoms and exhibited less safety behaviours (such as handwashing and mask wearing), which they believed was evidence of  “pandemic fatigue.” Another study by Kimhi and colleagues found that facing a second wave, participants had reduced resilience. After the shock of the initial wave, it appears that people are facing the second wave with a more resigned and negatively toned attitude, and this is what second-wave dream content reflects – less intensity but increased negativity.

With the dissemination of effective vaccines, it appears the waves of new infection have subsided from tsunami scale to a much more manageable level, especially among vaccinated populations. But vaccine availability and uptake is variable, and the waves continue to roll out in an unpredictable fashion, making this challenging time a kind of ongoing global experiment. The initial shock of the pandemic elicited such a strong shift in our collective dream lives that it spurred the publication of dozens of studies looking into dreams. Hopefully as the degree of disruption subsides, our shared interest in dreams will remain.

Do you know someone who suffers from frequent nightmares?
Or are you a parent concerned about the frequency and intensity of your child’s bad dreams?
Learn why treating nightmares is both essential and surprisingly simple in these two online course about nightmare relief.
Nightmare Treatment Imperative – The complete course for Clinicians
Nightmare Relief for Everyone. A little course designed to help everyone!

References

Kimhi, S.; Eshel, Y.; Marciano, H.; Adini, B. (2020). A Renewed Outbreak of the COVID−19 Pandemic: A Longitudinal Study of Distress, Resilience, and Subjective Well-Being. Int. J. Environ. Res. Public Health, 17, 7743.

Moradian, S., Bäuerle, A., Schweda, A., Musche, V., Kohler, H., Fink, M., Weismüller, B., Benecke, A. V., Dörrie, N., Skoda, E. M., & Teufel, M. (2021). Differences and similarities between the impact of the first and the second COVID-19-lockdown on mental health and safety behaviour in Germany. Journal of public health (Oxford, England), fdab037. Advance online publication.

Pesonen, A.-K., Lipsanen, J., Halonen, R., Elovainio, M., Sandman, N., Mäkelä, J.-M., Antila, M., Béchard, D., Ollila, H. M., & Kuula, L. (2020). Pandemic dreams: Network analysis of dream content during the covid-19 lockdown. Frontiers in Psychology, 11.

Tu, Z. H., He, J. W., & Zhou, N. (2020). Sleep quality and mood symptoms in conscripted frontline nurse in Wuhan, China during COVID-19 outbreak: A cross-sectional study. Medicine, 99(26), e20769.

 

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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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Dream Changes During the Pandemic Reflect Massive Collective Trauma

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A multinational study concludes that dreams are a reflection of massive collective trauma, and that dreams and dream recall must be integrated into approaches for improving mental health and health in general.

By Dr. Leslie Ellis

Since the beginning of the COVID-19 pandemic, the world has collectively been dreaming more, and our dreams have reflected the rise in stress levels, fear and uncertainty. A group of 23 researchers from 14 countries teamed up to take an in-depth look at how the pandemic has affected our dream recall and how this impacts health and mental health. They conclude that dreams are “an often-forgotten expression of the existential situation of individuals” and that they need to be integrated into how we understand and support mental health.

A recent multinational study of more than 19,000 adults explored the associations between dream recall frequency and related social, health and mental health factors, comparing data prior to and during the pandemic across four continents and 14 countries. Higher dream recall was linked with nightmares, sleep talking, recurrent disturbing thoughts and PTSD symptoms. As in previous studies, this one showed that women have been affected more than men, but also that those aged 55-64 had lower dream recall than younger people.

While the higher intensity of emotion during the pandemic has generated more dream recall — associated with more PTSD symptoms, problems with sleep maintenance, more nightmares and parasomnias — there is one interesting finding that bears further inquiry. Contrary to earlier studies, in the one, high dream recall was negatively associated with depression and anxiety. This could be because dreaming can help regulate the strong emotions people are experiencing in these turbulent times. However, the authors speculate that it could also be the result of the dream-dampening effect of anti-depressant medication. They said not enough specific data was collected to solve this riddle.

The study’s authors wrote: “The COVID-19 crisis has touched every person in the world in some way, whether it is related to becoming infected, suffering financially, through reduced social contacts, missed opportunities, or an inability to get required supplies and materials. It has become a communal trauma that has a profound impact on people around the world. One of the most difficult aspects of the pandemic is social isolation and confinement. Solitude goes against our inborn social instincts to form and maintain relationships as human beings and live in herd- or swarm-like alignments. Recent research has shown that the pandemic has led to increased anxiety levels, panic attacks, irrational fears, post-traumatic stress, depression, fatigue, reduced sleep quality, and sleep disturbances. Given the effects it has had on our everyday lives, perhaps it is unsurprising that COVID-19 has crept into our dreams.”

Earlier, smaller studies in various parts of the world (China, Italy, USA) have corroborated the findings that our dreams have been more intense and frequent during the pandemic, and that there are differences in how men and women have been dreaming. For example, a US study found that women with higher education were affected more than others, and several Italian studies showed that while all of us have experienced an increase in dream recall, women have been more affected.

“Since the pandemic has reportedly led to worsened mental health and higher levels of depression, anxiety, distress and symptoms of PTSD, heightened dream recall frequency might be an expression of the current mental health status,” according to the study authors. Women may be more affected as they have had to face more of the load – including increased childcare and health care responsibilities and greater job losses.

In their concluding comments, the authors called for more attention to dreams in mental health care and in general. “Dreams and dream activity are an often-forgotten expression of the existential situation of individuals. Based on our results, we assume that disruption in sleep patterns due to changes caused by the pandemic explains the increase in dream recall. Additionally, we propose that the observed increased dream recall frequency in our sample is an expression of the emotional intense and demanding experience of the current situation and could be an indicator that the pandemic is indeed turning into a collective trauma… Therefore, dreams and dream recall deserve more attention as potential support for coping with crisis situations, such as the COVID-19 pandemic and overall in supporting psychological wellbeing. Dreams and dream recall need to be accepted more and integrated into approaches for improving mental health and health in general.”

 

If you are a mental health professional interested in learning more about nightmares, parasomnias, 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 discounted during the pandemic. Please ask your clients if they have nightmares, and let them know they are treatable.

 

Check out the Short Focused Course on Nightmare Treatment using THIS LINK. 

References

Fränkl E, Scarpelli S, Nadorff MR, Bjorvatn B, Bolstad CJ, Chan NY, Chung F, Dauvilliers Y, Espie CA, Inoue Y, Leger D, Macêdo T, Matsui K, Merikanto I, Morin CM, Mota-Rolim S, Partinen M, Penzel T, Plazzi G, Sieminski M, Wing YK, De Gennaro L, Holzinger B. How our Dreams Changed During the COVID-19 Pandemic: Effects and Correlates of Dream Recall Frequency – a Multinational Study on 19,355 Adults. Nat Sci Sleep. 2021;13:1573-1591
https://doi.org/10.2147/NSS.S324142

Iorio I, Sommantico M, Parrello S. Dreaming in the time of COVID-19: a quali-quantitative Italian study. Dreaming. 2020;30(3):199–215. doi:10.1037/drm0000142

Nielsen T. Infectious dreams. How the COVID-19 pandemic is changing our sleeping lives. Sci Am. 2020;323:31–35.

Pesonen A-K, Lipsanen J, Halonen R, et al. Pandemic dreams: network analysis of dream content during the COVID-19 lockdown. Front Psychol. 2020;11:2569. doi:10.3389/fpsyg.2020.573961

Scarpelli S, Alfonsi V, Mangiaruga A, et al. Pandemic nightmares: effects on dream activity of the COVID-19 lockdown in Italy. J Sleep Res. 2021;e13300. doi:10.1111/jsr.13300

Schredl M, Bulkeley K. Dreaming and the COVID-19 pandemic: a survey in a U.S. sample. Dreaming. 2020;30(3):189–198. doi:10.1037/drm0000146

 

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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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Nightmare Relief from a Single Phone Session

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A recent study showed that even one session of nightmare treatment can be enough to significantly reduce the frequency and distress of nightmares. Katharin Luth and two other German researchers studied this low-threshold intevention, stressing the need for easy access to treatment because so often, nightmares are both underdiagnosed and untreated.

In the study, 28 people were given a half-hour phone session that provided information on what causes nightmares, and then offered a short version of Imagery Rehearsal Therapy (IRT), which asks the dreamer to write down their nightmare, imagine a new ending or revised version and visualize this new version for 5-10 minutes a day.

After 8 weeks of self-practice, the participants were asked about the impact on their nightmares. Participants were either students or patients from a sleep laboratory, and there was no control group.  Follow-up calls determined that 64% of participants’ nightmare frequency was reduced, 29 percent were unchanged and 7 percent experienced an increase in nightmare frequency.

Results were very similar for nightmare distress, which was reduced significantly for 63% of participants and most (78%) reported little or no distress post treatment. Of the 28 participants, 17 decreased distress, 9 remained the same and 1 experienced an increase.

The researchers also asked participants about their subjective experience with the treatment, and found that 2 of the 28 thought the treatment itself was scary because the process began with imagining their nightmares. There were far more positive reports (19) and 3 found immediate relief, saying, “The dreams completely disappeared as if they were switched off.”

All but one person in the study found the process helpful or very helpful. Effect sizes (d=1.92) were very large, possibly because for every person in the study, this was the first time their nightmares were addressed by a professional. For some, the simple idea that nightmares could be treated was a revelation, and then, to have a tool that they could use on their own brought them a greater sense of safety.

The authors concluded, “Because of the simplicity and the effectiveness of this method, we stress the idea put forward by many dream researchers that such easily accessibly offers for nightmare treatment should be implemented in our health care system.”

Some further resources:

Help for nightmare sufferers (free PDF) CLICK HERE

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.

Lüth, K., Schmitt, J. & Schredl, M. Conquering nightmares on the phone: one-session counseling using imagery rehearsal therapy. Somnologie (2021). https://doi.org/10.1007/s11818-021-00320-w

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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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.