What Is Imagery Rehearsal Therapy (IRT)?

First, what exactly is a nightmare? “Nightmares are vivid, realistic, and disturbing dreams typically involving threats to survival or security, which often evoke emotions of anxiety, fear or terror,” according to the American Academy of Sleep Medicine (AASM).

IRT can vary based on your needs and each therapist’s approach. But at its core, IRT directly targets nightmares to reduce bad dreams.

The AASM recommends IRT to treat nightmares and nightmare disorder associated with PTSD.

Nightmare disorder affects about 4% of adults. Living with this condition means you experience recurrent disturbing dreams that cause distress and disrupt different areas of life — like work or school.

Research has shown that IRT:

• reduces how often nightmares happen
• lessens distress caused by the nightmares
• improves sleep quality

In addition, this study examined the effectiveness of imagery rescripting, a piece of IRT for people with nightmare disorder. Imagery rescripting helps you change the nightmare, so it turns out in a way that doesn’t lead to distress.

Similar to other studies, researchers found that imagery rescripting reduced how often the nightmares happened and the distress they caused for people with nightmare disorder — and these effects lasted 3 and 6 months later.

Imagery rescripting also reduced:

• nights with nightmares
• insomnia
• trauma symptoms
• unhelpful beliefs about the nightmares

Another study tested IRT in 20 people with difficult-to-treat co-occurring conditions in a psychiatric hospital. They received IRT in addition to other therapy. Overall, these people had fewer, less intense nightmares and better quality sleep.

And according to this review of treatments for nightmares in people with PTSD, IRT also reduced:

• disturbing dreams
• PTSD symptoms
• anxiety

In the same review, the researcher notes that results in veterans with PTSD have been mixed. But other factors — such as different versions of IRT — could explain these findings.

Although IRT is based on the idea that traumatic events cause nightmares, it doesn’t focus on exploring that trauma. Instead, IRT treats nightmares as a specific issue that you can address.

IRT also teaches that nightmares actually serve a “helpful” purpose. For example, nightmares might help you emotionally process a traumatic event. But over time, these bad dreams hurt more than they help.

So IRT might teach you to view nightmares as habits or learned behaviors — ones that you can alter and adjust so they no longer disturb you.

Another core belief of IRT is that working with dreams during the day can influence your nighttime dreams, and as an extension of that, your nightmares.

You can use IRT in a one-on-one or group format. Each person’s situation, condition, nightmare complexity, and intensity are different, so the number of sessions and other IRT variables will differ.

There are also different versions of IRT, and they come with slightly different elements and instructions. For example, some versions include keeping a sleep diary and practicing relaxation techniques.

In general, IRT involves three stages:

• selecting a less intense nightmare (if possible, one that isn’t a replay of the traumatic event because the goal is not to trigger a strong emotional response)
• changing the nightmare — some versions advise changing it however you want, while others suggest creating a positive ending
• rehearsing your new dream up to 20 minutes each day for about a week

In an IRT session, you may be surprised (or relieved) to learn that you don’t discuss the details of your trauma or even the traumatic content of your nightmares. While an IRT therapist doesn’t discount your traumatic experiences, the focus is on addressing the nightmares.

Early sessions of IRT usually include discussing how the therapy works and responding to any of your questions or concerns. Your therapist can also teach you about nightmares and their connection to sleep quality.

For example, when you have nightmares, it’s natural to want to avoid them — and that’s how you might end up avoiding sleep or experiencing insomnia.

In IRT, you begin by picking one less intense nightmare to work with. You also focus on practicing one new dream at a time.

One key to remember is that you don’t need to go through every single bad dream. After revising and rehearsing a few disturbing dreams, you’ll likely notice fewer other nightmares, too.

Like other forms of cognitive behavior therapy, IRT also includes homework: Outside of therapy, you might practice pleasant imagery exercises. Once you’ve created your new dream, you could also rehearse it for up to 20 minutes a day.

Goals of IRT can include:

Untying your identity from your nightmares

Because nightmares (and other symptoms) can impact your entire life, you might start to believe that having bad dreams is inevitable — or even that having them is linked to your identity. According to 2006 research, this is similar to when people don’t believe they can stop smoking because they’ve been doing it for such a long time.

Though not everyone who has nightmares holds this belief or identity, it’s common and understandable. But it can keep the nightmares going.

So one major goal of IRT is to realize your identity isn’t tied to your nightmares. Changing this learned belief can help you stop the nightmares.

Reducing nightmares

In IRT, you reduce nightmares by creating new dreams with positive, pleasant, or empowering images. These images will be different for every person, but the key is to pick what resonates with you.

Some people choose to change a few elements of a dream, while others create a completely new story.

For example, this might mean adding helpful characters or changing the setting to somewhere safe.

Sleeping better

In reducing disturbing dreams, IRT also aims to help you get a good night’s sleep. It could also help you manage:

• your fears about going to sleep
• how often you wake up at night
• restlessness during sleep

Better sleep can also produce other benefits, such as less anxiety and more daytime energy.

Having nightmares can make you feel helpless. But in imagery rehearsal therapy (IRT), you change those dreams and empower yourself with the techniques to manage them.

IRT isn’t widely available. To start your search, you can ask your doctor or a loved one to recommend therapists who specialize in trauma, nightmares, or sleep (or the mental health condition you might have).

Another option is to search online at the Association for Behavioral and Cognitive Therapies for a cognitive behavioral therapist.

After picking several therapists you like, you can interview them by asking these questions (and anything else you’d like to know):

• Have you treated people using imagery rehearsal therapy?
• What is your experience working with people with trauma?
• What treatment approaches do you use for trauma?
• What is your experience treating nightmares?
• What is your perspective on nightmares and how to reduce them?