A MINI-COURSE FOR CLINICIANS AND TRAUMA WORKERS
ON POSTTRAUMATIC NIGHTMARES
By Alan Siegel, Ph.D.
I.) THERAPEUTIC USE OF DREAMS FOR TRAUMA SURVIVORS
1)ENCOURAGE VERBALIZATION AND EXPLORATION OF POST-TRAUMATIC DREAMS: Verbalization and repetition of troubling dream content may bring a catharsis, including normalization of fears, desensitization of nightmare and its troubling content, and the emergence of new themes and renewed capacity to "play" with the dream images.
2)WELCOME, REASSURE, WITNESS, EMPATHIZE WITH THE EMOTIONS OF THE TRAUMA SURVIVOR'S DREAMS: Listening, affirming the importance of the dream and its telling, reassuring the dreamer to quell persistent anxiety, and helping the dreamer to name and describe the difficult emotions in the dream if they can tolerate it at that stage in therapy. Defer active interpretation and create a zone of safety to allow the dreamer to tolerate free associating.
3) HELP THE DREAMER BREAK THE SPELL OF THE NIGHTMARES: Inviting the telling of the dream and accepting its upsetting content begins to transform the dreamer's anxiety and phobic avoidance and may create a corrective emotional experience convincing them that their dream will not hurt others, provoke rejection, or be overwhelming.
4) POINT OUT NORMALITY OF INTERMITTENT NIGHTMARES: Nightmares are both a common feature of PTSD and a normal reaction to any stressor. The presence of nightmares may be a sign of positive adaptation wherein the dreamer can tolerate the remembering of upsetting conflicts as opposed to avoiding and denying them.
5) TAKE AN INVENTORY OF PREVIOUS LOSSES/TRAUMAS: This will help explain the nightmare and point to likely areas of impasse provoked by the trauma.
II.) WHO HAS PTSD NIGHTMARES?
1) THOSE WHO SUFFERED MORE OVERWHELMING TRAUMAS WITH GREATER THREAT, PHYSICAL OR EMOTIONAL INJURY. This may apply especially to those who are closer to ground zero in a disaster such as the World Trade Center bombing.
2) THOSE WITH MORE PRESENT AND PRE-EXISTING VULNERABILITY BASED ON PAST TRAUMAS, CHARACTER PATHOLOGY, CURRENT STRESSORS, AND POOR SUPPORT NETWORK AND TREATMENT OPTIONS.
3) LIFELONG NIGHTMARE SUFFERERS DON'T NECESSARILY DEVELOP PTSD NIGHTMARES.
4) THOSE WHOSE TRAUMAS OCCURRED AT A VULNERABLE POINTSâ€“I.E. YOUNG SOLDIERS, ABUSE SURVIVORS.
5) THOSE WHOSE TRAUMAS CAUSE A DOMINO EFFECT OF OTHER STRESSFUL LIFE CIRCUMSTANCES THAT BLOCK RECOVERY OR EXACERBATE THE CORE EMOTIONAL WOUND SUSTAINED IN THE TRAUMA.
6) THOSE WITH FEWER RESOURCES IN TERMS OF EMOTIONAL/ SOCIAL SUPPORT.
7) THOSE WHO ARE NEAR-MISS TRAUMA SURVIVORS WHO RECEIVE NO VALIDATION AND BEAR THE HIDDEN WOUNDS OF SURVIVOR GUILT.
III.) COMMON NIGHTMARE THEMES
2) BEING CHASED OR KIDNAPED (Animal chasing are more common in children)
3) REJECTION, ABANDONMENT, BETRAYAL, OR HUMILIATION
4) NATURAL DISASTERS: EARTHQUAKES, TIDAL WAVES, TORNADOES, FLOODS
5) TECHNOLOGICAL DISASTERS SUCH AS EXPLOSIONS, FIRE, NUCLEAR WAR AND CHEMICAL CONTAMINATION, PLANE CRASHES.
6) VIOLENT ATTACK AND/OR INJURY TO SELF OR OTHERS.
7) GHOSTS RETURNING FROM THE DEAD IN A FRIGHTENING FORM
8) CARS OR PLANES GOING OUT OF CONTROL OR CRASHING
9) BEING PARALYZED OR UNABLE TO RESPOND AN URGENT OR LIFE THREATENING CHALLENGE
10) ILLNESSES SUCH AS CANCER, AIDS, PARALYSIS
11) MORTAL THREATS FROM ATTACKERS, THIEVES, ANIMALS OR CREATURES
IV.) HOW POSTTRAUMATIC (PTSD) NIGHTMARES ARE DIFFERENT?
1) PTSD NIGHTMARES ARE MORE EMOTIONALLY INTRUSIVE AND ANXIETY-PROVOKING.
2)BLANK OR CONTENT-LESS NIGHTMARES MAY OCCUR BEFORE THE DREAMER CAN TOLERATE ANY RECALL OF THE AFFECTS CONNECTED TO THE TRAUMA.
3)THEY MAY BE REPETITIVE AND UNCHANGING NIGHTMARES WITH MINIMAL ADAPTIVE RESPONSE TO THREATS ARISING WITHIN THE DREAM.
4) PTSD NIGHTMARES INSISTENTLY REPEAT SOME ASPECTS OF THE TRAUMA BUT WITH SOME ELEMENTS CHANGED OR MISSING. E.g. a wildfire becomes a rageful animal or a murderer becomes a kidnapper who assaults someone else while the dreamer watches.
5)ENCAPSULATION: LIKE A PSYCHOLOGICAL ABSCESS, INTOLERABLE EMOTIONS AND CONFLICTS LINKED TO THE TRAUMA CONTINUE TO INFECT THE PSYCHE BUT ARE WALLED OFF FROM CONSCIOUSNESS, YET PERSISTENT IN DREAMS.
6) FADING: AS A TRAUMA IS RESOLVED, THERE IS LESS FIXATION ON THE TRAUMA AS THE MAJOR THEME IN DREAMS AND TRAUMA-RELATED CONFLICTS ARE MIXED WITH CURRENT ISSUES AND CHALLENGES.
V.) DIAGNOSTIC AND THERAPEUTIC STRATEGIES FOR WORKING WITH POSTTRAUMATIC DREAMS AND NIGHTMARES
1) SEARCH THE DREAM FOR SIGNS OF ADVERSARIAL FORCES AND THEMES OF THREAT: Begins after event but nightmares may reemerge at anniversaries and with new stresses.
2)IDENTIFY PARTIAL CONFRONTATIONS AND ATTEMPTS TO ENCOUNTER ADVERSARIAL THEMES RELATED TO THE TRAUMA: Fighting back, running away, seeking help, more symbolic dreams, may indicate early stages of mobilizing defenses, which allow working through.
3) EMPHASIZE HOPEFUL SIGNS AND POINT OUT IMPASSES: Dreams involving conflict and struggle may indicate progress is occurring in resolution of the trauma.
4) ASSESS FOR ENCAPSULATION AND FADING OF THE TRAUMATIC CONFLICTS.
5) EXTREME FORMS OF AGGRESSION, INJURY, MORTAL THREAT, DEATH, DESTRUCTION, SUICIDE, SADOMASOCHISM, MAY SIGNAL FRAGILE OR FAILING EGO DEFENSES. It is best to look at a series of dreams to verify patterns.
6) ASSUME THE DREAMER IS IN DENIAL/EMOTIONAL SHOCK and look to dreams to highlight unresolved issues for repetition and working through.
7) FRIGHTENING DREAMS MAY SIGNAL LONG-DELAYED RELEASE OF CONFRONTATION with the traumatic emotions or a recent stirring of anxieties and threats to self from a more recent event.
8) GAIN ACCESS THROUGH REPETITIVE DREAMS AND THEMES to the hidden emotional wounds that may paralyze recovery. Dreams circumvent or get around defenses.
9) EXPECT REPETITIVE DREAM THEMES WITH SYMBOLISM LINKED TO EARLIER LOSSES AND TRAUMAS: Most posttraumatic dreams blend contemporary threats to the Self with parallel wounds from the past.
10) DREAMS THAT SEEM OBVIOUSLY RELATED TO THE TRAUMA MAY HAVE DEEP AND MULTIFACETED MEANING.
11) DREAMS DIRECTLY ABOUT THE TRAUMA MAY LATER BE A SCREEN FOR MORE CONTEMPORARY STRESSES OR CONFLICTS.
12)ANNIVERSARIES MAY PROVOKE RENEWED POSTTRAUMATIC DREAMS AND/OR DREAMS SIGNALING DEEPER RESOLUTION.
VI.) GENERAL PRINCIPLES OF DREAM INTERPRETATION
1) Begin with the patient's associations and stay with them.
2) Emphasize the process of exploration rather than the end product of interpretation.
3) Use your own associations and empathy as a guide.
4) Not every dream can or should be interpreted in depth.
5) Some can be listened to and witnessed and some can be worked in depth.
6) You don't have to know the answer to explore a dream. Use your feeling and imagination.
VII.) DREAMING THE DREAM ONWARD
Creative Exercises For Exploring Your Dreams
1. Dream Space: (Basic exercise that precedes all others below). Close your eyes, relax your body and imagine that you are re-entering and re-experiencing your dream complete with feelings and sensory experience. Spend from 1 to 5 minutes in the "Dream Space" before preceding to any of the other exercises below.
2. Automatic Writing: After completing the Dream Space exercise, take a pen and write all thoughts, ideas, feelings and associations. Write as fast as you can without censoring and without stopping the movement of your pen. Spend from 2 to 10 minutes or more.
3. Dialogue: Create a written dialogue, like a play script, between two characters or elements of your dream. Again keep your pen moving as fast as you can. Do not plan or censor and allow the unexpected.
4. Telling and Retelling Your Dream: Tell your dream in the present tense once or twice. Be aware of feelings, associations and body sensations. Tell your dream again from the perspective of an entirely different dream character. Note your feelings and how they change as you tell and retell your dream. Tell a dream you have written in your journal without looking and then read it out loud. Note what you have left out, embellished or change.
5. Dramatizing Parts of Your Dream: Dramatize parts of you dream playing two roles yourself or having others play one or more roles. Re-enact some of the key physical movements in the dream and note what feelings emerge.
6. Dream Drawing Technique: Have a group of people listen to a dream and all draw it as if it were there own dream. Share impressions. Draw pictures of a childhood dream or recurring nightmare. Don't worry about being realistic. Concentrate on color and emotions in your drawings as well as characters and events.
7. Dreams and Creative Movement: Use dance, improvisational movement or other physical expression to elaborate your dream. Assume poses and positions of various dream characters and note your emotional and sensory reactions.
8. Creating a New Dream Ending: Use your imagination and continue your dream onward. Write it our or just fantasize a new ending. Take the dream in a different directions or try to bring the dream to a more resolved ending.
9. Dream Incubation and Problem Solving: Ask your dreams an important but open_ended question and sleep on it. Pose the question to yourself and form it into a mantra. Write the question or issue in your journal or put it on a slip of paper and put it under your pillow. The more you ponder the question consciously the more likely a dream will respond.
10. Sharing and Exchange Dreams: Share dreams and insights from exercises with a trusted friend, relative or your partner. Sharing dream will often stimulate more dreaming, more sharing and possibly mutual dreams.
11. Keep a Glossary of Common and Recurring Symbols in your dream journal. Note repetitive characters from the present and past, recurring locations, emotions and conflicts in your dreams. Ponder possible meanings.
12.Keep an Intensive Dream Journal For 2 Weeks During Periods of Crisis or Transition Looks for feelings, conflicts and solutions that may help you understand and resolve the emotional challenges you are facing. During a crisis, conscious feelings may be blocked or numb put unconscious, dream images reveal the stages of reactions to a crisis or transition such as recovering from grief or trauma or responding to a move or job transition.
Alan Siegel, Ph.D. is Past-President of the Association for the Study of Dreams and Chair Person of Continuing Education for ASD. He is independent practice in Berkeley, CA and is Assistant Clinical Professor, University of California, Berkeley, Department of Psychology. He is author of Dreams that can change your life (Putnam/Berkley, 1996) and co-author with Kelly Bulkeley of Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares.
REFERENCES ON POSTTRAUMATIC DREAMS
Association for the Study of Dreams Website WWW.ASDREAMS.ORG
Contains articles from the journal Dreaming and magazine Dream Time
Brenneis, B. (1994). "Can early trauma be reconstructed from dreams? On the relationship of dreams to trauma." Psychoanalytic Psychology 11(4): 429-447.
Terr, L. (1990). Too scared to cry: How trauma affects children and ultimately us all. New York, Basic Books. Contains a chapter on repetitive dreams of Chowchilla kidnap victim research conducted by Terr.
Barrett, D. (1996) Trauma and Dreams. Cambridge: Harvard University Press.
Wilmer, H. A. (1996). The Healing Nightmare: War Dreams of Vietnam Veterans. Trauma and Dreams. D. Barrett. Cambridge: Harvard Univ. Press
Hartmann, E. (1996). Who Develops PTSD Nightmares and Who Doesn't. Trauma and Dreams. D. Barrett. Cambridge, MA, Harvard University Press:
Hartman, Ernest. (1984). The Nightmare: The Psychology and Biology of Terrifying Dreams. (New York: Basic Books).
Kellerman, H., Ed. (1987). The Nightmare: Psychological and biological foundations. New York, Columbia University Press.
Lansky, M. R., Ed. (1992). Essential papers on dreams. New York, New York University Press. Compendium of classic psychoanalytic papers.
Levitan, H. (1980). The Dream in Traumatic States. The Dream in Clinical Practice. M. D. Joseph M. Natterson. New York, Jason Aronson, Inc,: 271-281.
Mack, J. (1974). Nightmares and Human Conflict. Boston, Houghton Mifflin.
Natterson, J. M., Ed. (1980). The Dream in clinical practice. New York, Jason Aronson, Inc. Theoretical and clinical papers by Breger, Levitan and others.
Scheaffer, Charles (ed) Clinical Handbook of Sleep Disorders in Children. (NY Aronson, 1995)
Siegel, A. (1996) Dreams of Firestorm Survivors. In Trauma and Dreams
Harvard University Press edited by Deirdre Barrett.
Siegel, A. (1996) Dreams That Can Change Your Life: Navigating Life's Passages Through Turning Points Dreams. New York: Putnam. Chapters on posttraumatic dreams, divorce, grief, pregnancy, marriage, midlife, and illness.
Siegel, A. and Bulkeley, K. (1998) Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares. New York: Random House. Chapters on children's posttraumatic nightmares related to trauma, divorce, crisis as well as normal developmental transitions.
Terr, L. (1990). Too scared to cry. New York, Basic Books. PTSD nightmares of Chowchilla kidnap victims.
Wallace, M. E. P., Howard J. (1980). The Dream in Brief Psychotherapy. The Dream in Clinical Practice. M. Joseph M. Natterson. New York, Jason Aronson, Inc.: 405-426. Extended vignettes of the dreams of a rape survivor.
Copyright ©2003 Alan Siegel
Reprinted with permission
The Association for the Study of Dreams.
All Rights Reserved