Imagination rehearsal therapy: what does it consist of and how does it work?

A type of therapy that has been shown to be very effective against recurrent nightmares.

Nightmares are unpleasant dreams that cause high anxiety while they are being experienced. This is a normal phenomenon and one that we have all experienced; However, when they become recurrent, we can speak of nightmare disorder..

Imagination rehearsal therapy is an effective type of therapy to eliminate them.. In this article we will know what this technique consists of, how it is applied, the three steps that compose it and what the scientific evidence says about it. In addition, we will see what some authors think about the mechanism that explains its efficacy.

Nightmares and nightmare disorder

Imagery rehearsal therapy is a type of therapy used to treat nightmares. Nightmares are terrifying dreams that we have all experienced at some time in our lives.

They occur mostly in childhood and adolescence (to a lesser extent), and having them is not considered pathological; However, when their frequency is exaggerated, and when they cause clinically significant discomfort, it is considered a sleep disorder (nightmare disorder). (nightmare disorder).

• Recommended article: "The 7 main sleep disorders".

Thus, as a disorder, it is classified in the DSM-IV-TR and DSM-5 (Diagnostic Manuals of Mental Disorders) as a sleep disorder. The nightmare disorder consists of the occurrence of unpleasant and even terrifying dreams, which awaken the subject and leave a vivid memory (which gradually fades). All this causes discomfort to the subject and / or interferes with their normal functioning.

Nightmares are a type of parasomnias, and occur in the second half of sleep, in the REM phase. Parasomnias are sleep disturbances that occur during awakening, in the sleep-wake transition or during sleep (specifically, in the REM phase).

In nightmare disorder, once the person wakes up, he or she recovers the oriented and vigil state.

Imagery rehearsal therapy: characteristics

Imagery Rehearsal Therapy (IRT) is considered the therapy of choice for the treatment of nightmares. is considered the therapy of choice for the treatment of nightmare disorder, or simply nightmares, especially in childhood (although it is the first choice).especially in childhood (although it is useful at all ages). Imagery Rehearsal Therapy has been used for over 10 years with war veterans and people who have suffered physical abuse, all of whom have recurrent nightmares.

The efficacy of this therapy has been investigated through different studies, and these studies show that it is an effective therapy for reducing and even eliminating nightmares. In addition, other studies have compared the efficacy of imagery rehearsal therapy with the use of Venlafaxine (antidepressant; selective serotonin and norepinephrine reuptake inhibitor) or prazosin (drug used to treat hypertension), and have shown that the efficacy of IRT and that of the drugs is similar.

Imagination rehearsal therapy aims to have the patient rework the nightmare he or she has had, including a positive and pleasant ending; that is, to modify it as he or she wishes to make it pleasant. In the end, the patient learns to "change" the content of his or her own nightmares, exercising control over them, even to the extent that he or she is able to "change" the content of the nightmare.by exercising control over them even while sleeping. But how does he achieve this?

Steps

Let's look at it through the four steps of Imagination Rehearsal Therapy.

1. Writing down the nightmare

The first step to be taken by the patient is to write down (and describe) the nightmare he/she has had.Ideally, this should be done immediately after waking up, since as time goes by, the nightmare will be forgotten. If this is not possible, the ideal is to select a nightmare with the therapist and write it down.

It is advisable to do it on a piece of paper and in natural light, or artificial light but with low intensity, right next to the bed. The use of a tablet or phone is not recommended, since the type of light emitted by these devices is harmful in this case, and would interfere with the recall of the dream.

2. Rewriting the nightmare

The second step of the imaginative rehearsal therapy consists in rewriting the nightmare.The subject rewrites it so that it ends up becoming a pleasant dream, or at least with a happy ending. That is, the subject changes the nightmare to his liking, and describes in detail the new version. This new version is then discussed with the therapist.

In order to rewrite the nightmare, the use of imagination will be fundamental. This is not an easy step, as it requires practice and perseverance; the ultimate goal is for the subject to be able to include pleasant details, and to imagine it as vividly and realistically as possible.

3. Induce the intention to dream again.

There are people who can have "lucid dreams"; that is, they can dream "being aware" that they are dreaming during the dream itself. This means that they can even "intervene" within the dream, or influence it.

This ability to lucid dream, however, is an ability that few people have. That is why most subjects will have to train and practice to achieve it, or at least to achieve a similar experience.

That is why, in the third step of the imagination rehearsal therapy, the subject, before falling asleep, will try to influence the fact of having the nightmare again. For this purpose, he will apply three steps:

3.1. Repetition of a sentence.

Just before falling asleep, the subject will say to himself: "If I start having the nightmare, or when I have it, I will be able to influence to have a much more pleasant sleep.". This phrase has to be repeated as a kind of "mantra", internalizing it in the head.

3.2. Imagining a rewritten dream

In this case, the subject should imagine the pleasant dream that he or she rewrote through the nightmare, in detail. This step can be repeated; the more the subject imagines the dream, the better.

The objective is for the subject to mentally review the sequence of the new images during wakefulness.. Ideally, the subject should spend between 5 and 20 minutes a day. On the other hand, it is advisable to work with a maximum of 2 or 3 nightmares at a time.

3.3. Repeat step 1

The last part of the third step of the Imagination Rehearsal Therapy is for the subject to repeat the initial phrase (from step 1) as many times as necessary.

4. Success + Repeat the process

The fourth and final step of the Imagery Rehearsal Therapy comes when the subject succeeds in when the nightmare is successfully replaced by the pleasant dream (i.e., dreaming it), or when the subject succeeds in influencing the dream.or when you manage to influence the course of the nightmare to change it for the better. That is to say, when success is achieved and therefore the nightmare disappears.

The last step, in turn, includes repeating the previous steps whenever necessary, when new nightmares appear.

On the other hand, ideally, the technique should be tested for at least ten nights, in order to see the results obtained, the possible obstacles that appear, the resistances, improvements, etc.

Mechanism of action

Although Imaginal Rehearsal Therapy is considered an effective therapy, it needs to be further investigated, as the studies carried out are single case reports and some controlled studies..

Where there is controversy, however, is in determining precisely the mechanism of action of the technique, i.e., why is it effective? Two authors have expressed their opinion on this subject: Marks and Krakow.

Thus, while Marks proposes three key elements in imagery rehearsal therapy, which are exposure, abreaction (relief) and mastery (learning anxiety management skills), Krakow speaks of 1 essential element: the process of sleep modification (according to this author, this would be the element that would explain the effectiveness of the technique).

Bibliographical references:

• American Psychiatric Association -APA- (2014). DSM-5. Diagnostic and statistical manual of mental disorders. Madrid: Panamericana.

• Aurora, R., Zak, R., Auerbach, et al. (2010). Best practice guideline for the treatment of nightmare disorder in adults. Journal of clinical sleep medicine, 6, 389-401.

• Pérez, M., Fernández, J.R,; Fernández, C. and Amigo, I. (2010). Guide to effective psychological treatments I and II:. Madrid: Pirámide.