1. The programme at a glance
Indication. The programme is for people who have repeated nightmares that wake them, leave a precise memory and take a toll: distress, a fear of going to bed, degraded sleep, fatigue or mood that suffers as a result. It is intended for adolescents from the age of twelve and for adults, whether the nightmares appeared with no identifiable cause — they are then called idiopathic — or after a traumatic event. Section 27 explains how to adapt the work for children aged six to eleven.
Reference model. The programme is built on imagery rehearsal, often referred to by its acronym IRT (imagery rehearsal therapy). The person chooses a nightmare, writes a new version of it, changed however they wish, and rehearses this new version in imagination, while awake, for a few minutes every day (Krakow and Zadra, 2006). It is the only approach that the American Academy of Sleep Medicine (AASM) classes as "recommended", for post-traumatic nightmares as for others (Morgenthaler et al., 2018). The programme surrounds it with three things: careful medical sorting, work on the night — waking, the fear of going to sleep, substances —, and an explicit link with the treatment of post-traumatic stress and with that of insomnia.
Format. The programme has seven sessions. The first assesses and sorts; the next five do the work; the last takes stock. The first four are weekly, the next three two weeks apart, to give the rehearsal time to act. Individually, they last 50 to 60 minutes, the first 75. In a group of four to eight people, they last 90 minutes, and session 1 takes place as an individual interview. Two booster sessions follow, at one and three months. Section 14 justifies this format.
Mechanism targeted. The programme does not seek to eliminate unpleasant dreams, which are part of every sleeper's life; it aims at three changes: that the chronic nightmare loses its frequency and its charge, because another scenario has been learned; that the person regains the sense of having a hold on what their sleep produces; and that the night becomes once again a time when one sleeps, not a time one dreads.
| Session |
Purpose |
Session deliverable |
| 1 |
Assess, sort, make safe |
Sorting done, risk assessed, baseline measures, diary handed out |
| 2 |
Understand, and prepare the imagination |
Cycle drawn, goals written, first imagery exercise |
| 3 |
Rewrite a first nightmare |
New version written and rehearsed in session |
| 4 |
Rehearse, adjust |
Rehearsal checked, version corrected, interim measures |
| 5 |
Widen, and tame the night |
Second nightmare chosen, plan for waking written |
| 6 |
The sleep around it |
Fear of bedtime, substances and insomnia treated or referred |
| 7 |
Review, plan, relapse |
Measures repeated, plan for a return written |
What the person takes away. The person leaves with nine printable worksheets, listed in section 33: my night diary, understanding my nightmares, practising imagining, rewriting my nightmare, my rehearsal, on waking and before sleeping, protecting my sleep, the corner for those close to me, my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things set it apart. It targets a symptom, the nightmare, that the other manuals often encounter and refer here: Post-traumatic stress disorder in adults: a therapist's manual cites it among the symptoms that persist when the rest improves, and Treating chronic insomnia in adults: a therapist's manual recalls that it has its own treatment. It does not ask the person to recount the trauma: the work is on what sleep produces, not on what happened. And it begins with sorting that is not psychological: part of what looks like nightmares falls to the doctor.
2. Before you start
The four prior decisions
Is it really a nightmare? Waking with a start is not always a nightmare. A person who screams without waking and remembers nothing, a person who thrashes about while dreaming to the point of injury, waking up gasping for breath, brief and identical episodes several times a night: these are other pictures, which call for other responses (section 8). This question is asked at session 1, point by point, even when the picture seems obvious.
Is there established post-traumatic stress? When the nightmares began after a serious event and come with memories that intrude during the day, avoidance and a state of alert, the picture is then that of post-traumatic stress disorder, of which the nightmares are only one part. This does not close off this programme, but it decides its place (section 25).
Is there suicide risk? It is looked for explicitly, at session 1 and whenever the nights get worse (section 9).
Is there a medical or toxic cause keeping the whole thing going? Look for a medication introduced, increased or stopped, alcohol taken so as not to dream, cannabis withdrawal or sleep apnoea. Treating the nightmares without looking at these causes is like bailing out water without plugging the leak (section 8).
What this programme does not treat
It does not, on its own, treat post-traumatic stress. Trauma is treated with Post-traumatic stress disorder in adults: a therapist's manual, or with Post-traumatic stress disorder in children and adolescents: a therapist's manual in young people. This programme can precede, accompany or follow that treatment (section 25).
It does not treat the parasomnias of deep slow-wave sleep — sleep terrors, sleepwalking —, nor REM sleep behaviour disorder. The former are managed according to Sleep disorders in children and adolescents: a therapist's manual, session M3, in young people, and with a sleep physician in adults; the latter falls to a neurologist or a sleep physician.
It does not treat chronic insomnia, which often accompanies nightmares. That is treated with Treating chronic insomnia in adults: a therapist's manual, in parallel or afterwards (section 24).
It is not intended, on its own, for children under twelve. For them, the parents carry a large part of the work, and the format changes: section 27 refers to sessions M1 and M2 of Sleep disorders in children and adolescents: a therapist's manual.
How to use it
Read the whole manual before the first session, in particular sections 3, 8, 9 and 23 — sorting, differential diagnosis, safety and imagery rehearsal in detail —, then section 25 if the nightmares are post-traumatic. Each session is described using the same framework: the objective, the sequence of steps, what you say and do not say, common mistakes, and the criterion for moving on.
Three warnings specific to this reason for consultation.
The nightmare draws out the account. The person wants to tell it in full, and the therapist, curious or anxious to understand properly, lets them. Twenty minutes later, the person is shaken, and the session has produced nothing: a detailed account is not a step in this treatment. A title and a few sentences are enough to know where to change the story (section 23).
Interpretation is also a temptation. Looking for what the nightmare "means" may interest both the person and the therapist. It is not forbidden, but it is not what makes the treatment work: the best-supported method rests on no interpretation at all (Krakow and Zadra, 2006). If the person is keen on it, keep it for another time.
And the simplicity is disconcerting. Rewriting a dream and rehearsing it for ten minutes a day seems too simple to many patients, and sometimes to the therapist. Yet it is actual, daily rehearsal that decides the outcome; checking it session after session is the most important task in this programme.
3. Three situations not to be confused
The same words — "I have nightmares" — cover three situations that do not call for the same response.
1. Occasional nightmares
What you observe. The person has nightmares from time to time, more numerous during a demanding period — exams, a bereavement, a separation, a house move —, which recede when the period passes. They sleep, function during the day, and do not dread bedtime.
What points the way. The nightmares have no real impact, and they vary: they follow the curve of stress, and do not repeat identically for months.
What this implies. The protocol is not needed. One information session is enough: you explain what a nightmare is and what makes it worse — lack of sleep, evening alcohol —, and you leave the door open. The self-help guide Nightmares: taking back your nights can be given.
2. Idiopathic nightmare disorder
What you observe. The person has had frequent nightmares for months or years, often since childhood or since a long-past period, without any traumatic event at their origin. They often return to the same themes — being chased, falling, arriving too late, losing someone —, wake the person, and leave distress or fatigue that affects the day.
What points the way. The diagnosis rests on the impact, which section 10 measures, and on the chronicity.
What this implies. This is the direct indication for this programme. In the trial by Kunze et al. (2017), which mainly involved idiopathic nightmares, both imagery rescripting and exposure to the content of the nightmare reduced frequency and distress compared with a waiting list.
3. Post-traumatic nightmares
What you observe. The nightmares appeared after a serious event. Some replay the scene almost identically; others transpose it into another setting, with the same emotion.
What points the way. Two cases arise. Either the nightmares are part of established post-traumatic stress, with daytime re-experiencing, avoidance and hyperarousal; according to the AASM, up to 80% of people suffering from post-traumatic stress report nightmares (Morgenthaler et al., 2018). Or they persist on their own, while the rest has settled, or after successful treatment of the trauma; in a study of military personnel who no longer met the criteria for post-traumatic stress after their treatment, 13% still complained of nightmares, compared with 57% of insomnia (Pruiksma et al., 2016).
What this implies. In the first case, the treatment of the trauma is central, and this programme is coordinated with it (section 25). In the second, this programme is the indication, with the precautions of section 23 regarding traumatic content.
The other situations to rule out
What looks like a nightmare and is not one must be ruled out: sleep terrors and sleepwalking, REM sleep behaviour disorder, the awakenings of apnoea, nocturnal panic attacks, hallucinations at sleep onset and sleep paralysis, certain epilepsies. Section 8 describes them in detail.
Nightmares that signal a current danger. A person who has nightmares about violence because they still live with the violent person does not first need to rewrite their dreams: they need safety (section 9).
The three sorting questions
"When it happens, are you awake straight away, and do you remember the dream?" This separates the nightmare, which wakes the person and leaves a precise memory, from the parasomnias of deep slow-wave sleep, in which the person is confused and remembers nothing.
"Did it start after something serious? And during the day, do images of that event force themselves on you?" This isolates post-traumatic stress.
"What changed in the weeks when it appeared: a medication, a dose, stopping something, alcohol, cannabis?" This isolates toxic and medication-related causes.
4. What a nightmare is
The description
A nightmare is a very unpleasant dream, often long and structured like a story, which wakes the person, and of which they keep a precise memory. On waking, they are immediately oriented: they know where they are and that it was a dream, which does not stop their heart from pounding or make it any easier to get back to sleep. The content most often involves a threat to life, safety or physical integrity: being chased, attacked, trapped, losing someone.
Fear is not the only emotion at play: anger, sadness, shame, disgust or guilt may dominate. A dream in which one loses one's child in a crowd and wakes up in tears is a nightmare just as much as a chase. This matters in practice: the new version will seek to change the dominant emotion, whatever it is.
The time of night
The nightmare arises from REM sleep, the phase in which the brain is very active and in which most long, image-rich dreams take place. These phases lengthen as the night goes on; that is why idiopathic nightmares occur mainly in the second half. Sleep terrors and sleepwalking, which arise from deep slow-wave sleep, occur by contrast mainly in the first third. This marker helps with sorting, without being absolute: post-traumatic nightmares conform to it less clearly, and it is the picture as a whole that decides.
Frequency and impact
The AASM estimates that nightmare disorder affects around 4% of adults (Morgenthaler et al., 2018). Frequency is not what makes the disorder: distress and impact are. Two people who each have two nightmares a week can be very different: one goes back to sleep and thinks no more about it, the other dreads bedtime every evening, puts off going to bed and spends their mornings anxious about the previous night's dream. The distinction between frequency and distress was established early in the research (Belicki, 1992), and the measures in section 10 separate them.
The impact takes several forms, which have to be looked for one by one: a fear of going to bed, which leads to putting off bedtime and shortens the nights; awakenings followed by long difficulty getting back to sleep; fatigue, irritability, low mood the next day; daytime anxiety at the thought of the dream; behaviours aimed at not dreaming — alcohol, cannabis, a sleeping tablet, screens until exhaustion; a couple's life disrupted by the awakenings; shame, in adults, at talking about "nightmares".
Two families, one treatment
Idiopathic and post-traumatic nightmares differ in their origin and often in their content, but they respond to the same treatment, and the AASM recommends IRT for both (Morgenthaler et al., 2018). What changes is the context: in post-traumatic nightmares, the rest of the post-traumatic stress matters, the content may reactivate memories, and dissociation or re-experiencing during the exercise call for precautions (sections 23 and 25).
5. What maintains nightmares
An isolated nightmare passes. What turns it into a companion every night stems partly from factors that cannot be controlled — a temperament, a trauma, a demanding period — and partly from understandable responses, which need to be identified because the treatment targets them.
The sleep habit
Krakow and Zadra (2006) argue that a nightmare that has been recurring for a long time can become a disorder in its own right, and no longer merely the symptom of something else: it sometimes continues for years after the event that gave rise to it has settled, like a learned behaviour. This is the idea on which the treatment is based: if the nightmare is partly a habit, another one can be learned.
Alertness, and fear that is slow to fade
A consensus paper reviewing the origin and treatment of nightmare disorder describes two ingredients that reinforce each other: a high level of alertness, by day as by night, and a difficulty extinguishing fear, that is, allowing a frightening image to lose its charge when it returns without anything bad happening (Gieselmann et al., 2019). A trauma, early adversity, a sensitive temperament, the tendency to forcibly push away distressing thoughts, and sometimes sleep-related breathing disorders prepare the ground.
The fear of going to sleep
After a few weeks, it is no longer the nightmare that is dreaded, but the night. People put off bedtime, fall asleep in front of a screen so as not to "go there" with their eyes open, sleep with the light on, their back to the wall. Sleep shortens, the debt builds up, fatigue rises, and alertness with it. This is avoidance, in the sense understood by cognitive and behavioural therapies: it brings relief tonight and maintains the fear on the evenings that follow.
Substances taken so as not to dream
Evening alcohol speeds up falling asleep, then leaves a fragmented second half of the night. When cannabis is stopped, disturbing dreams are among the signs of withdrawal described in the DSM-5-TR (American Psychiatric Association, 2022). In both cases, what brings relief for a few nights prepares a rebound.
Replaying the film, or forcibly chasing it away
On waking, then during the day, the person sees the images again, recounts the nightmare in detail, looks for what it means. Telling it in order to be heard brings relief; telling it over and over rehearses the scenario and reactivates the fear. The opposite effort, forbidding oneself to think about it, is no better: the suppression of distressing thoughts is among the factors identified by the consensus paper (Gieselmann et al., 2019).
Beliefs about nightmares
"If I'm still dreaming about that, it means I haven't got over it." "My brain is trying to warn me about something." "If I fall asleep, it will come back." These sentences add a second layer of anxiety to the first, and they keep people awake as much as the nightmare itself.
Insomnia settling in
After a nightmare, the heart takes time to slow down; over the weeks, the bed becomes the place where one lies in wait. Insomnia is added, sometimes more troublesome than the nightmares themselves, and it has its own maintaining mechanisms, described in Treating chronic insomnia in adults: a therapist's manual, section 3.
The complete cycle
A nightmare wakes the person at four in the morning. They stay awake, replay the images, worry about the next night. The next day, they are tired, tense, and they think about it. In the evening, they put off bedtime, have a drink, fall asleep late and badly. Lack of sleep, alcohol and alertness favour a new nightmare. This is the diagram you draw with them at session 2.