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Forty-eight comments were posted on the recent New York Times article on treatment of chronic nightmares. Reading them was illuminating and encouraging, because the overwhelming majority of writers showed a great deal of common sense in their appreciation for the use of imagery rehearsal therapy (IRT). Among this group, there were numerous stories of those who had received similar instructions from a parent or friend who advised them to “change” something about their nightmare scenarios. In other words, these people or their children had lived through a process of suffering from nightmares and then successfully eradicated them through an instruction that afforded them a measure of influence over the problem.

This common sense perspective fits perfectly with our experiences in clinical practice and research investigations. To this day, we are not convinced that IRT is actually a therapy. We have long believed that IRT simply represents the formalization of a natural, working process of the human mind, and we’ve assumed the technique has probably been in operation for millennia. Why wouldn’t it seem logical or reasonable for people to imagine that their waking images influence their sleeping images? Dream research has shown that daytime reflections or even bedtime “preemptive” images may induce specific modes or content in dreams.

If there is a therapy aspect to IRT, it might be through the process of mastery. Consciously, patients feel empowered by IRT by taking control of something that previously felt like it was an uncontrollable and unconscious process. Perhaps even greater potency arises from the actual changes of “dream” content that IRT necessitates. We have speculated that these changes may have psychodynamic properties, that is, by encouraging the patient to intuit changes in their dreams, could it be that such changes reflect efforts to alter or resolve underlying conflicts? Although there are some patients who change their dreams entirely to something that appears to have no relationship to the original dream content, this approach is not the norm. Typically, patients retain some aspects of the disturbing dream, both in terms of content and apparent emotional states. For these reasons, we have stuck with Joseph Neidhardt’s original prescription, “change the nightmare anyway you wish.”

Summing up for those who support IRT, it seems to be a very natural use of the mind’s eye, and the mind’s eye is certainly a powerful gateway through which to understand and solve numerous problems experienced in the waking state. No doubt, many nightmare sufferers have been fortunate to have grasped this perspective and reversed their bad dreams rather easily, presumably because waking imagery work influences sleeping imagery.

For the Jungians who commented, apparently IRT is difficult to chew on, digest, and absorb. Somehow it’s a quick fix and superficial solution whose benefits are largely outweighed by the loss of insights from “inappropriate” alteration of the dream. To these psychoanalysts, may I be so presumptuous as to remind them that Freud originally theorized that “dreams were the guardian of sleep.” In other words, Freud must have believed that sleep was also a relevant factor in this equation. Why else would dreams allegedly protect sleep? To me, this construct implies that a brilliant psychoanalyst understood that sleep must be important; there is a context to dreams, they occur during sleep, and therefore the interpretation of dreams while valuable is not an exclusive proposition.

I certainly concur with the view that dream interpretation work is an asset to therapy, but it’s remarkable that more 75% of all chronic nightmare patients we’ve seen have previously completed more than a few sessions of psychotherapy of some type and yet reported minimal improvement in their nightmares. Arguably, many did not use dream interpretation work in their psychotherapy. Regardless, I’m a board-certified internist and sleep specialist and when a patient seeks help, my goal is help them sleep better.

Ask most of our IRT patients if they lost something by replacing their nightmares with a good night’s sleep, and we would predict most would be perplexed by the question. “Thanks for giving me back my sleep,” was the most common refrain from those who successfully conquered their disturbing dreams and nightmares. If asked to keep the nightmares or gain the sleep, we’ve seen a few cases where patients were so overwhelmed by the sudden disappearance of their bad dreams they immediately stopped IRT so the nightmares might return. In every one of these few cases, several months later the patient decided enough is enough, returned to IRT practice, and the bad dreams abated once again.

As Sarah Kershaw’s article described, we’ve seen a great deal of complexity to nightmare disturbances and related sleep problems in PTSD patients. In patients presenting to our sleep center with the problem of nightmares, at least 70% also have obstructive sleep apnea and up to 25% have leg movement problems. So, here’s a conundrum the Jungians will need to sort out. What about the sleep apnea patient who has severe nightmares that completely disappear once breathing is restored to normal with the artificial device known as PAP therapy (positive airway pressure)? Should we stop treatment with PAP therapy to insure the nightmare patient completes his or her 5 years of appropriate Jungian psychoanalysis to uncover the hidden meanings of nightmares? Or, since sleep apnea worsens heart disease, hypertension, and depression, would it be reasonable to continue with PAP therapy and just call the elimination of nightmares a “side-effect” of unknown clinical consequences.

What may seem ironic or not to Jungians is that I started my career in sleep medicine through the field of dream research, spending several years studying the field and presenting our nightmare treatment research to the Association for the Study of Dreams of which I am a current member. I also co-write a book with Dr. Neidhardt introducing IRT (Conquering Bad Dreams & Nightmares, 1992), but it also included a lengthy, detailed section on Dr. Neidhardt’s dream interpretation techniques to solve nightmare problems. So, I strongly endorse dream interpretation techniques, including Jungian work, and remain firmly convinced that dream interpretation therapies are vastly underrated and underused. Dr. Neidhardt, a psychiatrist now practicing in Santa Fe, taught me how dream interpretation work is an incredibly incisive technique for understanding emotional conflict and subsequent attempts at emotional processing to resolve such conflicts. I still use these techniques, but my clinical practice population steers me towards greater usage of IRT.

I must say it never occurred to me there was something mutually exclusive about IRT and dream interpretation work, although most people who share this view—patient or therapist—recognize they would not necessarily attempt both techniques at the same time on the same dream; however, I’m certain there are therapists who would have the skill to do just that if a patient were motivated to do so.

We known a lot more about sleep and dreams than we did 100 years ago, and what we know is that things that disrupt sleep cause mental and physical health problems, serious problems that clearly impact daytime functioning and quality of life. Having suffered from sleep problems for 35 years prior to successful treatment, I know first hand how much impairment can be caused by these nocturnal mischief-makers of which nightmares are only one—one that often runs with a pack. I would hope the Jungians would regroup and ask themselves whether they are on solid scientific footing when they would choose salvaging a nightmare disorder in favor of a good night’s sleep. The number of nightmare patients with undiagnosed physiological sleep disorders is not small. Overemphasizing the dream work increases the risk for missing these diagnoses, which will lead to no small amount of harm to these patients. Sleep is as precious as dreams, maybe more so.

Following a Script to Escape a Nightmare