Understanding Trauma Nightmares
Nightmares are a very common symptom, especially among people with PTSD. However, they have not been the focus of much clinical attention, and you likely have not had specific training in nightmare treatment. Patients commonly report significant impacts of recurrent nightmares and go to great lengths to avoid their nightmares. Therapists can instinctively take an avoidant approach as well, conceptualizing their patients’ nightmares as a triggering event that is better left without direct exploration or intervention and that will hopefully recede over the course of treatment. Very often the nightmares persist even after treatment, frustrating the patient and therapist alike.
I lived out this tension as I started my career treating patients with PTSD, and what I learned from them about their nightmares led me to develop Trauma Nightmare Treatment (TNT) to confront and overcome this issue.
Nightmares are dreams that cause awakening and clinically significant distress. As a therapist specializing in PTSD, my focus lies in what I will call Trauma Nightmares, those experienced by people involved in a situation that meets Criterion A of the DSM-5 PTSD Diagnosis. Compared to ordinary nightmares unconnected to trauma (i.e., idiopathic), Trauma Nightmares tend to be more severe, recur more often, and cause more distress.
The key innovation of Trauma Nightmare Treatment is to view the Trauma Nightmare as a healthy part of processing a trauma that is stuck, instead of as a symptom to be avoided.
Trauma Nightmares contain references to the dreamer’s traumatic experience, which can be either:
- Memory (or biographical) – directly replaying scenes from the person’s trauma
- Symbolic (or semi-biographical) – containing themes from the trauma, but with events that did not actually occur
However, both types of Trauma Nightmares are different from the real-life experience of the trauma in that the dreamer has definite foreknowledge of what is to come in the dream, often heightening the emotional distress. Also, because Trauma Nightmares are experienced in the present, dreamers usually attempt to stop the trauma event from occurring during the dream, which can lead to a cycle of failed attempts to prevent the trauma that can last for years, or even decades.
Because Trauma Nightmares are directly caused by the dreamer’s reaction to the traumatic event they experienced, they can serve as a direct indication of where the dreamer has become stuck in processing their trauma. Using Trauma Nightmare Treatment, we can show patients how to take advantage of the differences between dreams and real life, allowing them to choose a new set of responses during the nightmare that would not make sense during an actual event.
By rethinking the Trauma Nightmare in this manner, we can see that its purpose is to deliver a message or a lesson for the dreamer, likely related to them not yet having accepted what happened. This lack of acceptance plays out in the dreamer’s response during the nightmare (e.g., trying to run, fight back, hide, or otherwise attempt to prevent the trauma), which is doomed to fail.
The goal of TNT is to replace the stuck response with a new response that is congruent with both the emotional need and the biographical truth. Then, by using dream re-scripting to rehearse the new healthy response to the same Trauma Nightmare, we can unlock the stuck point, promote acceptance, and end the Trauma Nightmare for good. This can all happen in a single session.
Dream re-scripting is the principle behind Imagery Rehearsal Therapy (IRT), the therapy that current nightmare treatments are based on, and which Trauma Nightmare Treatment uses in a new, effective way.
Ways to learn TNT
TNT is new, and you have an opportunity to be one of the first to try this novel approach to treating nightmares. I have been convinced by its success in many cases in my own clinical work, and I want to share what I have learned.
If you are interested, I am offering group consultation currently, and soon two other avenues for you to participate.
Small group consultations
Learn about TNT and case consultation (available now)
Online or in-person training
For larger groups (coming soon)
CEU credits for TNT training
(Coming by spring 2025)
FAQs
What does my patient need to start TNT?
All they need is a willingness to discuss their Trauma Nightmare and to practice the TNT techniques.
Can this really work in one session?
Yes, in my experience, this is often the case. Other IRT approaches also use one-session delivery.
What if it does not work after the first session?
TNT is based on finding the solution to the place where the patient is stuck in the Trauma Nightmare. If the Trauma Nightmare continues unchanged, then we likely did not find the correct solution, and we can use that understanding to work toward it.
Commonly, unsuccessful solutions try to “fix” the problem by changing the reality of what happened in the trauma, which the unconscious self/soul will resist.
Also, if the patient does not actually rehearse the new dream prior to bed, the technique is much less effective.
What if other Trauma Nightmares emerge after the primary one resolves?
This is a common occurrence. Trauma Nightmares seem to occur in the order of importance, so the primary one is the worst. After that resolves, secondary Trauma Nightmares may emerge. It is to be expected, and therapists can assure patients that the same technique will work on secondary nightmares.
Eventually, the hope is to foster a sense of curiosity and detachment that will allow patients to resolve further less intense nightmares on their own.
How is TNT different from existing nightmare treatments?
Imagery Rehearsal Therapy (IRT) for nightmares was first published in 1978, and its dream rescripting technique forms the basis for the current state-of-the-art nightmare therapies. These include IRT; Exposure, Relaxation, and Rescripting Therapy (ERRT); and the new Cognitive Behavioral Therapy for Nightmares (CBTn).
All these treatments share a fairly avoidant response to the Trauma Nightmare itself, whereas TNT uses the Trauma Nightmare to lock in on the stuck points and address them. The other approaches suggest altering the nightmare content to be something positive, which only sidesteps the true conflict at the heart of the Trauma Nightmare. TNT instead looks to empower people to change their response to the actual situation within the Trauma Nightmare. Confronting it in this new way allows them to fully process the trauma.
For example, a person who was at Ground Zero on 9/11 might have nightmares of people falling. An avoidant response would be to change the dream to save those people somehow. Unfortunately, that is not what happened, so the gains for this approach are limited. TNT will focus on letting go of the impossible attempt to change the past and instead help the patient to shift their reaction inside the Trauma Nightmare to the event that actually happened.
Nightmares occur in the present, and by working in the present toward acceptance and letting go of irrational guilt that is keeping them stuck, patients can undertake the specific healing actions they decide are best for their individual trauma.
Will TNT work on idiopathic nightmares not related to trauma?
Unknown, although this is not a focus of TNT. The basis of TNT is to interpret the response in the Trauma Nightmare based on the stuck point related to that trauma. Without an understanding of the cause of the nightmare, most of TNT will not apply. Using the dream rescripting framework of IRT at the core of TNT might still be helpful, or you could use traditional IRT techniques as well.
What if my patient does not recall their nightmares?
This can be challenging for TNT or any IRT-based approach. Firstly, I would encourage use of a notepad to record nightmares upon awakening, which can improve recall. However, if they have no memory of the nightmare content but the nightmares began after their trauma, and they can recall the trauma, I would recommend using an evidence-based treatment for PTSD (e.g., CPT, EMDR, WET, or PE).