Dan sat motionless, riveted to his chair as he recalled his recurrent nightmare. “Every night …” He trailed off and faded back. “It’s the eyes. I see his eyes! Staring at me.”
Dan was recalling a soldier, frozen to death and still at his post. The memory, too, was frozen in time because Dan’s war was at the core of his disorder. It was why he recounted the nightmare to me, his therapist. “Can anything be done?” he asked me. “I’d give anything not to remember those eyes!”
Unfortunately, Dan died not long after I began researching treatments for nightmares and sleep disturbance. Saddened but undaunted, I continued the search, using this veteran’s penetrating cry for help as the galvanizing event to develop an effective approach for other clients who were suffering as Dan had.
Ethically, counselors must practice within their areas of competency. This article describes the process three members of the American Counseling Association followed to gain the skills necessary to ethically treat nightmares associated with combat-related post-traumatic stress disorder. We engaged in research and training and became innovative in combining therapies to develop what we believe is an effective protocol for addressing this issue.
While living with combat-related PTSD, Dan voiced a desperate need to eliminate the nightmare that repeatedly pierced his nights. His tormented cry became a rallying point for the clinic where he was treated. The clinic had many clients similar to Dan, but at that time, no specific treatment was available to address their nightmares directly. The general treatment was to use exposure therapy, based on emotional processing theory developed by Edna Foa and Michael Kozak in the mid-1980s. This consisted of addressing the trauma in detail, keeping the client’s reactions within a therapeutic range to neither underaccess the “fear structures” nor overwhelm the client. The purpose was to help the client develop a mastery of the fear and thus process traumatic events one at a time.
Building a program
Dr. Richard Ross led an investigation into PTSD and sleep in 1994, speculating that PTSD indeed might be considered a REM sleep disorder. While so doing, he and his team declared that nightmares were the “hallmark” of the disorder. In addition, Dr. Thomas Neylan and his team found that in a sample of 1,167 Vietnam veterans with PTSD, nearly 91 percent suffered significant disturbances to sleep.
Armed with this information, I began researching REM sleep and discovered an exceptionally useful book that helped to explain sleep itself — J. Allan Hobson’s Dreaming: An Introduction to the Science of Sleep. This provided me the foundation I needed to delve deeper into the world of dreaming. These lessons would later form the core of the psychoeducational portion of an outpatient treatment program.
Hobson’s book illuminated my understanding of the essence of dreaming and ignited some ideas for eliminating traumatic nightmares. According to Hobson, eliminating the nightmares would improve clients’ mood, concentration, learning and physical repair of the body and even enhance their immune systems. What was needed was a way to attack the nightmares themselves.
Karin Thompson, Michelle Hamilton and Jeffrey West addressed traumatic nightmares in their 1995 work with the Veterans Affairs hospital in New Orleans, developing an inpatient protocol specifically for nightmares associated with combat-related PTSD. They applied a technique called imagery rehearsal therapy (IRT) developed by Barry Krakow and reported that one-third of their patients eliminated the “target nightmare.” IRT works to eliminate nightmares by first allowing the veteran to address, rather than void, content. IRT helps the veteran to develop a mastery of the event rather than being victimized by the past trauma. “Rehearsal” aspects program a new response, thus allowing restorative sleep. Krakow’s research showed that at a 30-month follow-up, 68 percent of the subjects were able to sustain reductions in frequency of target nightmares. The IRT-based dream approach is essentially consistent with the basic premise of Foa and Kozak in that writing down the nightmare is an exposure to the traumatic content of PTSD. Even so, veterans would find this the most difficult step.
The challenge for what became known as “Dan’s cause” was to translate these inpatient protocols to an outpatient format. I began networking with other licensed professional counselors to obtain additional insight and support. Deb Breazzano, an LPC in the community, suggested a 90-day format to capture a full dream cycle and to quantify to each client not only reductions in nightmares but also the emergence of healing dreams. Veterans respond to group bonding, and trust is the currency exchanged among them. Therefore, a longer program would facilitate these bonds and allow for multiple approaches to address nightmares and dreaming. The content would be based in IRT and Jungian dream concepts, but the search was on for additional methods to beat the nightmares.
According to a study led by Victor Spoormaker in 2003, lucid dreaming was also effective in reducing nightmare frequency and intensity. Lucid dreaming is essentially becoming aware that you are indeed dreaming while asleep and then enabling yourself to guide the dream. Evidence was mounting that a stepwise approach to treating nightmares would work, with one successful application setting the foundation for the next. The program’s goal now had moved beyond just eliminating nightmares to helping clients achieve emotional and developmental growth.
During the course of developing the program, the agency that directed our clinic allowed me to train in Jungian dream analysis and supported a trip to Santa Fe, N.M., to hear Dr. Bessel van der Kolk speak on effective counseling skills for trauma. What he said — that an “effective trauma treatment must reset one’s limbic system” — became the keystone for my developing program. In effect, trauma is a sensorimotor process; according to Hobson, so is dreaming. So van der Kolk’s advice was simple yet profound: Treatment must provide an “action or escape” not present in the original trauma.
Now self-educated in the process of dreaming, networked with other therapists, supported by my agency, well-versed in current research and professionally trained in the arts of therapy and hypnotherapy, I formed a new premise: All traumatic nightmares are rehearsals of the survival instinct. Van der Kolk affirmed that the only real change for clients would come by resetting their limbic systems with an action or escape, thus eliminating the need for a traumatic rehearsal through nightmare. Therefore, IRT and its follow-ups would author the original nightmare and then reauthor a new outcome. This would result in breaking the repetitive, traumatic cycle. There was finally an answer to Dan’s impassioned plea for help. Rewrite the nightmare with a new ending by providing action or escape.
Laila Alsaffar teamed up with me to colead a men’s PTSD group at the clinic. Although it was too late to help Dan, we were nonetheless spurred on by Dan’s memory to help others. Dan was a big believer in the power of groups to heal, so it was altogether fitting that we were using a group format. We introduced veterans to basic dreaming concepts based on Hobson’s book and taught them how to develop sleep hygiene, practice relaxation, author their nightmare and its change, and apply reinforcing methods to turn the cessation of traumatic nightmares into real growth. At its end, we had developed a 13-week, self-contained program that employed most of the elements from a good anxiety reduction group. During the process, we discovered that nightmares are like a field full of thistles and thorns. IRT is akin to tilling that field. Lucid dreaming, Jungian concepts and relaxation techniques seed and fertilize the dense field, allowing it to transform into a sculpted garden.
In developing the program, we also wrote a manual for clients (as well as a version for therapists) that contained worksheets, report forms, reading material, exercises and illustrations. The first segment of the treatment program is designed to build group trust, strengthen support skills and reduce anxiety by providing basic psychoeducation on the sleeping brain. Educating group members on sleep hygiene helped them to gain ownership of the process over the course of the combined treatment. This was achieved, in part, because each person in the program shared what he was learning in group with a significant other, thus reinforcing the process.
Because they needed to overcome their tendency to avoid reminders of their individual traumas, the most critical juncture for the majority of the veterans was writing out their actual targeted nightmares. Most had worked to avoid this step for protracted periods of time before this therapy. The counselors encouraged each of the veterans to tackle his nightmare head-on, using each other and his family for support. Almost every one of the veterans reported how difficult the process of facing his torment was, yet nearly all of them experienced a reduction in nightmare frequency and intensity just before this phase, so they were encouraged to push through the echoes of fear imbedded in their memories. This step, combined with the “action-escape” rewrite of the nightmare, formed the middle or “core” of the combined treatment. The action-escape element restored personal control over what had been a feeling of powerlessness — in some cases, for decades.
Using lucid dreaming and Jungian concepts, the last phase featured action-escape and the use of sculpting dreamed objects as enhancements to the treatment. Participants found this a more joyful task. As though they were now a blank canvas, these war veterans had a new chance to create joyful and healing experiences through their dreams. Some who had suffered even more profoundly from their disorder than Dan experienced a kind of spiritual awakening. Before the treatment, it was as if the war had stolen their souls. But the release of fear through the processing of their nightmares seemed to present them with a new freedom from their pasts.
In the years that I practiced at the clinic, we helped approximately 80 veterans who were struggling with nightmares associated with PTSD. For the astute counselor willing to crack the books and enlist support, the potential is there for adapting workable therapies for many disorders faced by returning veterans.
Wayne A. Hankammer is a licensed professional counselor living in Artesia, N.M. He is a critical incident stress management instructor and specialist for the Federal Law Enforcement Training Center. Contact him at firstname.lastname@example.org.
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