Imagination rehearsal therapy: what is it and how does it work?

Nightmares are unpleasant dreams that cause high anxiety while being experienced. It is a normal phenomenon and one that we have all experienced; however, when these 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 make it up and what the scientific evidence says about it. In addition, we will see what some authors think about the mechanism that explains its effectiveness.

Nightmares and nightmare disorder

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

They appear mainly in childhood and adolescence (to a lesser extent), and the fact of having them is not considered something pathological; however, when its frequency is exaggerated, and when they cause clinically significant discomfort, it is considered a sleep disorder (nightmare disorder).

• Recommended article: "The 7 main sleep disorders"

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

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

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

Imagination Rehearsal Therapy: Features

Imagery Rehearsal Therapy (IRT) is considered the therapy of choice to treat nightmare disorder, or simply nightmares, especially in childhood (although it is useful at all ages). Imagination rehearsal therapy has been used for more than 10 years on war veterans and people who have suffered physical abuse, all of them with recurring nightmares.

The efficacy of this therapy has been investigated through different studies, and these show how it is an effective therapy to reduce and even to eliminate nightmares. Additionally, other studies have compared the efficacy of imaginative trial therapy with the use of venlafaxine (antidepressant; selective inhibitor of reuptake serotonin and norepinephrine) or prazosin (a drug used to treat hypertension), and have shown that the efficacy of IRT and that of drugs is similar.

Imagination rehearsal therapy aims for the patient to rework the nightmare he has had, including a positive and pleasant ending; in other words, modify it however you want to make it pleasant for you. In the end, the patient learns to "change" the content of his own nightmares, exerting control over them even while you sleep. But how does he get it?

Steps

Let's see you through the four steps of Imagination Rehearsal Therapy.

1. Write the nightmare

The first step that the patient must take is to write (and describe) the nightmare that he has had; The ideal is to do it immediately after waking up, since as time passes, it is forgotten. If this is not possible, the ideal is to select a nightmare with the therapist and write it down.

It is recommended that you do it on paper and in natural light, or artificial light but with low intensity, right next to the bed. The use of the tablet or the telephone is not recommended, since the type of light emitted by these devices is harmful in this case, and would interfere with the memory of sleep.

2. Rewrite the nightmare

The second step in Imagination Rehearsal Therapy is to rework the nightmare, in rewriting 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 the new version in detail. Later this new version will be discussed with the therapist.

To rewrite the nightmare, the use of imagination will be essential. It is not an easy step, since it requires practice and perseverance; the ultimate goal is for the subject to be able to include pleasing details, and to be imagined in the most vivid and realistic way possible.

3. Induce the intention to dream again

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

This ability to lucid dreaming, however, is a capacity 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.

For this reason, in the third step of the rehearsal therapy in imagination, the subject, before falling asleep, will try to influence the fact of having the nightmare again. To do this, you will apply three steps:

3.1. Repeating a phrase

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

3.2. Imagine dream rewritten

In this case, the subject must imagine the pleasant dream that he rewritten through the nightmare, in great 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, spend 5-20 minutes a day. On the other hand, it is recommended that you work with a maximum of 2 or 3 nightmares at the same time.

3.3. Repeat step 1

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

4. Success + Repeat the process

The fourth and final step of imagination rehearsal therapy arrives when it is possible to replace the nightmare with the pleasant dream (that is, dream it), or when the course of the nightmare is influenced to change it for the better. That is, 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, the ideal is to try the technique for at least ten nights, to see the results obtained, the possible obstacles that appear, the resistances, improvements, etc.

Mechanism of action

Although imaginative rehearsal therapy is considered an effective therapy, should be investigated further as the studies performed are single case reports and some controlled studies.

What is controversial, however, is precisely determining the mechanism of action of the technique; that is, why is it effective? Two authors are those who have opined on this issue: Marks and Krakow.

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

Bibliographic 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). Good practice guide for the treatment of nightmare disorder in adults. Journal of Clinical Sleep Medicine, 6, 389-401.

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