Category: Nightmares

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Dream therapy works: Study shows diagnostic and transformative power of clinical work with dreams

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In Angela’s dreams, there was always a similar theme. In them, she was climbing a mountain, an impossibly-steep slope that seemed to tower ever-higher so that no matter how hard she tried, she could never get to the top. Sometimes she met obstacles, weather, darkness, various elements that hindered her journey. Then one day, the way opened up. It was wide and clear, she felt strong and capable, with an inner conviction she would make it to the summit. This dream heralded a dramatic shift: an increase in agency in her dreaming life that was paralleled in her waking life. Recent research has shown this correlation is not unique to Angela. In fact, the ongoing pattern of dream life of clients in psychotherapy provides important diagnostic and prognostic information.

Nightmare treatment brings predictable shifts in dreaming patterns

In my doctoral research, my qualitative study of the way dreams changed for refugees with PTSD nightmares following dream therapy unearthed a promising pattern across cases. In these harrowing recurrent nightmares, the dream ego’s plight was always dire, the dreamer felt helpless, and would typically wake up in the most frightening part of the dream, about to be killed, kidnapped or in some way deeply traumatized. In the dreamwork, we invited them to imagine a new dream ending, and after this, the dream ego in subsequent dreams showed progressively more agency. In the dreams, the dream ego moved in reverse order of the nervous system’s response to threat: from freeze to flight to fight. Coinciding with this was a significant reduction in PTSD symptoms.

Study identifies the four most common dream patterns

A recent study of dream patterns as related to the psychotherapy process confirms this general progression. The researchers found that dreams generally follow one of the four most common patterns. In the first, the dream ego is threatened; second, the dream ego is confronted with a task or performance requirement; third is a mobility dream depicting some kind of journey; and fourth is a social interaction dream. Any of these patterns can get stuck in a repetitive pattern that the researchers found would coincide with some form of pathology. When the dream begins to shift, so does the dreamer.

For the study led by Roesler (2018), researchers analysed 202 dreams of 15 patients in psychoanalytic therapy and found that their patterns of dreaming corresponded closely with their psychological problems. For example when the dream ego is continually threatened, this corresponds with a weak ego structure, and as both the course of therapy and dreaming progressed, there was a noticeable growth in ego strength in both dreaming and waking life. For example, instead of trying to escape the threat, the dream ego might confront the threatening figures or actively fight, and ultimately succeed, or the threat itself transforms into something less dangerous For example, “In Case 5, in the first half of the series, the dream ego is threatened by snakes. Then in the midst of the dream series, a golden snake appears which is not dangerous” (p. 313). The author noted that these patterns of transformation occurred only in the cases where the therapist reported improvement in both symptoms and personality structure.

As dream ego becomes stronger, so does the dreamer

The relationship between dream patterns and the dreamer’s psychological health tended to move forward in predictable ways, and the patterns themselves formed a kind of continuum: dreams of a threatened dream ego would shift toward more engaged and empowered patterns such as journeys or social interactions. In general, an active dream ego with the ability to solve problems and exhibit agency correlates with psychological health in waking life.

What does this mean for therapists? The study demonstrates two good reasons to track and work with client’s dreams. First, the dreams provide diagnostic information and can indicate clinical progress. Second, working with the dreams themselves may be able to bring about the very changes the client seeking therapy is needing.

Dreams provide honest feedback to therapists

Jenkins (2014) conceives of dreamwork as an intervention in the dream life of the client. If it is effective, the dream life changes for the better. He wrote that “the dream work can then be judged by its influence on the next dream.” This gives the dream worker immediate feedback that is unfiltered: “It allows for an independent assessment rather than relying in the self-assessment of the dreamer.”

To return to Angela’s dream, the sudden shift in the dramatic landscape to something far less daunting, and her corresponding increase in agency and confidence could be viewed as a sign of success not just in the dream, but in the therapy process and in her life. Dream work that invites experiential connection with the dream to foster such shifts may be helpful not only in dream life, but in life in general, and the subsequent dreams can provide proof of success. If Angela next dreams of leading a successful expedition to the Everest summit, we know she is going to be just fine.

 

Jenkins, D. (2014). Assessing dream work: Conceptualizing dream work as an intervention in dream life. International Journal of Dream Research, 7(2), 121-128.

Roesler, C. (2018). Dream Content Corresponds with Dreamer’s Psychological Problems and Personality Structure and  with Improvement in Psychotherapy: A typology of Dream Patterns in Dream Series of Patients in Analytical Psychology. Dreaming, 28(4), 303-321.

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Whether and how to work with traumatic nightmares: An example from Auschwitz

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Many therapists I am teaching to work with dreams have expressed hesitation in working directly with their clients’ most challenging nightmares. They express a concern that talking about these highly disturbing dreams will stir up their client’s fears, possibly reinforce them and generally make matters worse. In a recent blog post, I presented some evidence that almost anything you try will be helpful; nightmares are treatable and should be addressed promptly and directly.

Philosopher Eugene Gendlin offered this piece of wisdom from his book, Focusing:  “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.”

Those who suffer from frequent, recurrent nightmares are already enduring them, so as Gendlin suggests, talking about them does not make them worse, but in fact tends to help. This idea was supported by a recent study looking at the dreams of those who suffered what is arguably the worst possible trauma: participants were all former prisoners of Auschwitz. Polish researcher Wojciech Owczarski analyzed more than 500 dreams of 127 former inmates and concluded that most of their dreams were adaptive on their own or had “therapeutic potential.”

Only 10 percent of the dreams were recurrent, repetitive dreams that replayed actual trauma memories; most had begun to weave in present experiences with the past, or were metaphors for the experience. Both of these kinds of dreams can be viewed as signs of potential recovery from the trauma. For example, one former inmate’s dreams of the concentration camp began to include his young wife, and he wrote, “There’s more confidence that both myself and my wife will survive.”

This research refutes an earlier study (Lavie and Kaminer, 1991) which suggested that in cases of severe traumatic experiences like the Holocaust, those who repressed their memories and did not examine their nightmares fared better. Owczarski found that while not all of the dreams of the Auschwitz survivors had therapeutic effects by themselves, “all of them seem useful and healing in psychotherapy, so suggesting patients repress their dreams would turn out to be a serious mistake.”

How to work with nightmares

So if even the most horrific dreams warrant attention in therapy, the next question is how to do this in a way that does not re-traumatize the client. In this, it can be helpful to take the lead from the dreams themselves as they are an indication of how far along the path to healing the dreamer has come. The man who dreams that his young wife is at Auschwitz with him has clearly come a long way towards recovery from his traumatic experience and would be able to discuss these dreams with relative ease.

In other dreams, you would have to be more tactful and resourceful to use the nightmare’s therapeutic potential. Recurrent dreams that replicate the trauma exactly demonstrate the least amount of progress toward healing – although they can be seen as a form of inner exposure therapy, a repeated calling for the dreamer to attend to the trauma. In these cases, forms of imagery therapy that invite the dreamer to continue the dream, and allow it to play forward have been shown to help.

Help manage fear responses

I believe that the key to working with highly charged material is to help the dreamer to manage their physiological responses, to learn to keep calm in the face of recalled trauma. This process involves establishing and safe and supportive connection with the client, teaching skills that help the client learn to cultivate calm and keep a safe distance from the material. For example, clients can be encouraged titrate: to work with the dream images one little piece at a time. They can also learn how to build an ‘observer self’ that is able to watch the trauma dream play out without the sense that they are reliving the experience.

There is more to this way of working than I can offer in detail here. The main point is that even with the worst nightmares, there is therapeutic potential and to avoid the discussion may well be a mistake. Chances are you won’t make it worse because your client is “already enduring it.” In fact, having someone accompany them into their darkest places demonstrates the danger has past and the trauma can be talked about constructively and healed.

 

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. CLICK HERE for a free PDF for clients: What You Can Do About Your Nightmares. Or check out our Short Focused Course on Nightmare Treatment using THIS LINK. 

 

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Nightmares are easily treatable, though too few seek help

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Taken together, the nightmare studies presented at the recent (June 2019) conference for the International Association for the Study of Dreams (IASD) offer compelling reasons for those who suffer from nightmares to seek any kind of treatment, and as soon as possible. The studies suggest that virtually all nightmare treatments are effective, and that the earlier nightmare disorder is treated the better. Current nightmare research was presented at an international dream conference held in a 900-year-old abbey in Kerkrade, The Netherlands. In this post, I will summarize the nightmare studies of greatest clinical relevance.

Michael Schredl conducted a four-year longitudinal study on nightmares and stress and found that nightmare frequency is generally stable from childhood onwards. He thinks nightmares may be due to emotional regulation issues rather than genetics. He said what increases nightmare frequency and distress is a rise in current anxiety and stress levels (vs. trait stress). Frequent nightmares in the past also predict frequent nightmares in the future. In terms of clinical implications, Schredl suggested that for those who suffer from frequent distressing nightmares, the earlier they seek treatment the better.

Too few seek treatment

Sadly, very few people seek help for their nightmares. Kateřina Surovcová conducted a qualitative study of the experiences of social dream sharing of nightmares. She noted that only one in 8 people seek help for their nightmares despite their detrimental effects. People are reluctant to share nightmares for fear of being seen as crazy, and because they don’t want to burden others with the darkness of their dreams. Yet talking about nightmares can bring a welcome sense of relief.

Another recent study, a randomized controlled trial by Carolin Schmid which compared two established imagery-based treatments, showed that all treatments are effective at reducing nightmare frequency and distress, even the control condition! For the many people who leave their nightmares untreated, it might help to know that virtually all treatment options are likely to be effective.

Just one treatment is effective

In the study, Schmid compared three different imagery-based methods. The first is imagery rehearsal therapy (IRT) which asks the client to imagine a new ending to their distressing dream and then rehearse it. The second is exposure therapy, in which the client is repeatedly exposed to their nightmare imagery. The third, an active rather than waitlist control, guides clients to imagine a safe place. Interestingly, all three methods worked equally well, and all worked with just one treatment session. So, in treating nightmares, it really is true that any treatment is better than no treatment, and the resulting decrease in nightmare frequency and distress occurs after just one treatment.

Schredl noted that in nightmare studies and clinical treatment, the distress caused by the nightmare is the most important variable, and the frequency is of secondary importance. He said people’s attitudes toward their nightmares matters. This is another area where clinical intervention can be very helpful. I can offer a personal example from my practice, an approach useful to any therapist wondering how to approach a challenging nightmare.

Improving attitudes toward nightmares

The images in nightmares can be gruesome and upsetting. However it helps to suggest to those who experience such dreams that the images are not meant to be taken literally, and that they may even be refer to something dramatically positive. Popular dreamworker Jeremy Taylor saw dream images of death, for example, as indicating a major transformation such as the cessation of an addiction. A client of mine dreamt of dismembering a woman, and this image lost its disturbing quality once she considered the ways she felt profoundly divided in her own life  and could see the image as an apt metaphor for this.

In my practice, I aim to encourage people who have nightmares to explore them with open curiosity, and in the course of experiential exploration, to befriend the dream images as much as possible. This shifts the dreamer’s attitude toward their nightmares, and as a result, they can often find them less distressing. This is one way to work with nightmares; what the research suggests is that almost anything works. So as a clinician, there is no need to shy away from dreamwork with clients who have nightmares, and in fact, good reasons to forge ahead.

 

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. CLICK HERE for a free PDF for clients: What You Can Do About Your Nightmares. Or check out our Short Focused Course on Nightmare Treatment using THIS LINK.