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.

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.

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ACT for PTSD: Nightmare Rehearsal Treatment

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