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.

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.

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.

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.