ACT for PTSD: Nightmare Rehearsal Treatment


Booz Allen
Department of Veterans Affairs
Yale University
University of Nevada, Reno

Key Points

  1. Nightmare rehearsal treatment is a type of exposure that helps reduce the severity and frequency of nightmares.
  2. It involves writing and rewriting a nightmare’s content in detail and changing one thing that can make the client aware that it’s not real.
  3. This technique can be adapted to fit the client’s needs; for example, when nightmares are about actual traumatic events and the outcome cannot be changed without invalidating the client.
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Treatment Progress

After four months of treatment, Deborah reduced alcohol use to a few drinks a week, and started to open up to her best friend about what she’d been dealing with. She refreshed her resume and started looking for jobs to apply to. However, her nightmares were still very upsetting and disruptive to her sleep. As she did well with written exposure, she agreed to try nightmare rehearsal treatment. That became the treatment focus for the next three to four weeks.

Nightmare Rehearsal Treatment (NRT)

NRT is similar to other types of exposure. The client writes about the nightmare in as much detail as possible, especially if it’s a recurring nightmare. They are then asked to alter just one detail, and rewrite the nightmare with that detail changed, again at a granular level of description. Then the client reads that account at least once a day, for as many weeks as is appropriate for their particular case.

In traditional NRT, it’s suggested that the changed detail is something prior to the most distressing element of the nightmare. For example, if the nightmare is that there’s a monster coming after them, the changed detail can be a closed door, so the monster can’t get in. But when nightmares are about an actual traumatic event, it can feel invalidating for the client to have to change a detail that negates the trauma they actually lived through.

Deborah’s Nightmares

Deborah had nightmares about the rape she experienced in Afghanistan, so it didn’t make sense to her to change the outcome, because it’s what happened to her. And of course, she also had a history of people not believing her.

So in her case, the discussion was about changing something separate from the trauma. What Deborah came up with was that, as the assailant got closer and more threatening, it began to snow. In that area of Afghanistan at the time she was there, it was summer. So that was an unusual detail she was able to describe, then read daily.

When she next attended therapy, she had done the homework, and it had started to snow in her nightmares. This gave her the awareness that the trauma wasn’t reoccurring, but was a dream. So she was able to wake herself up.

Deborah undertook NRT for a further three weeks, and the nightmares shifted somewhat. The treatment was adjusted based on feedback about the nightmares, and over time she reported a lot of relief. After that, the final month of her treatment was spent revisiting values, and adding committed actions to get her life back on track.

Looking for practical everyday tools? This print-friendly handout is just what you need. Click on the following link to download the PDF:

Nightmare Rehearsal Treatment for Trauma-Related Nightmares

This handout reviews nightmare rehearsal treatment, an exposure therapy technique to help clients mitigate the intensity and frequency of distressing nightmares. The process begins with a comprehensive narrative of the recurring nightmare from the client’s perspective. A single aspect of the narrative is then altered, while not invalidating the actual trauma. The client reads this revised narrative daily, developing the realization that the nightmare is a construct of their mind, not a replay of their trauma. Through regular feedback, the approach is adjusted to suit the client’s evolving needs. As the nightmares become less distressing or frequent, therapy shifts toward focusing on the client’s values and committed actions.


First, therapists should familiarize themselves with nightmare rehearsal treatment before using it in therapy. Explain its purpose and process to the client while emphasizing the aim of modifying nightmares through a single change in the details. Encourage your client to write a detailed narrative of their recurring nightmare, then guide them to alter one element of the narrative, ensuring it doesn’t invalidate their actual trauma. Instruct them to read this revised narrative daily, with the reading frequency being adjusted according to their progress. Each session should begin with a discussion on changes to the nightmares and emotional responses to the altered narrative, making appropriate treatment changes in response. As the nightmares become less distressing or frequent, shift the focus to the client’s values, discussing and setting committed actions that align with those values for them to regain a sense of control and direction in life.

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ACT for PTSD: Nightmare Rehearsal Treatment

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