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Section 4
Therapy for Trauma Nightmares

Question 4 | Test | Table of Contents

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In the last section, we discussed type ‘B’ night terrors.  Three factors involved with type ‘B’ night terrors that we examined were extreme trauma, complications resulting from type ‘B’ night terrors, and personality characteristics.

In this section, we will discuss the six step psychotherapeutic approach to type B night terrors. Clearly, you have experience addressing severe early or past traumas, related traumatic and health complications, and resultant interpersonal difficulties with your clients. This is precisely why night terror sufferers need a competent therapist to guide them through the necessary steps regarding dealing with trauma.

Also, the treatment of type B night terrors can be approached with some of the same methods you already use regarding anxiety disorders. Therefore, you already have the necessary expertise.  The purpose of this section is to provide additional direction in applying your expertise to the subject of night terrors. 

Jerry, introduced in the last section, was still suffering from night terrors well into adulthood, so there was no doubt that his condition was trauma related type B night terrors. With Jerry, I implemented a six step psychotherapeutic approach.

The six steps I used with Jerry were: following sleep guidelines, validating trauma and evaluating family ties, exploring present circumstances, addressing resultant health problems, allowing solitude, and implementing the steps simultaneously. As you listen to this section, consider your client. Could he or she benefit from listening to this section and how Jerry used this technique?

6-Step Psychotherapeutic Approach

♦ Step #1:  Following Sleep Guidelines
The first thing that Jerry did was to follow some guidelines designed to benefit all sleep disorder sufferers. I stated, "Consider eliminating all caffeine from your diet. Even that morning cup of joe should be eliminated." Other guidelines that Jerry adhered to included avoiding food three to four hours before bed, following a regular sleep schedule, avoiding exercise near his bedtime, ensuring quiet, and avoiding alcohol. 

Jerry stated, "I also got rid of the business phone I kept in bedroom. Now I reserve my bedroom strictly for sleeping."  In the attached reproducible client worksheets, these guidelines are thoroughly listed for distribution to your clients. Though these guidelines are common sense, could they benefit your Jerry?

♦ Step #2:  Validating Trauma and Evaluating Family Ties
The second step in this approach was for Jerry to validate his trauma and evaluate his family ties. Clearly, this step involves discovering your client’s past trauma. In cases involving severe repression, this may be difficult or even impossible. Clues to the nature of the trauma can be gathered either through sessions regarding associated dreams or interviews with family members. What methods do you use to discover repressed trauma in your clients? 

Jerry described a recurring sensation he experienced which he associated with his night terrors. Jerry stated, "After the terror is over, sometimes I’m sort of awake and I can remember feeling like I had been choking."  Through continued discussion, Jerry came to recall numerous occasions in which his mother would choke him as punishment for bad behavior.  I validated his trauma by sharing with Jerry some research which linked his abusive past with night terrors. 

At this point, Jerry’s therapy became more focused and productive.  Jerry stated, "I don’t think I ever really forgot or repressed those memories of my mom choking me, but I guess I rationalized it as harmless." 

Jerry stated, "Now I understand how screwed up my childhood really was. The dysfunction is clear when I think about my own kids suffering what I suffered."  To help Jerry make another connection, I asked, "How do you feel today when you talk to your parents?" Jerry responded, "I feel uncomfortable. Like I’m always on edge. In fact, now that I think about it, I have night terrors more often after I’ve been talking to mom." 

While your client may not feel compelled to sever dysfunctional family ties, Jerry felt he had to do so for his own good. Jerry stated, "If I’m going to get better, maybe I shouldn’t talk to her or my dad at all for a while." Would you agree that a decision to sever family ties cannot be made with any degree of reliability until the client has worked through the associated denial and suppression of the abuse?

Also, I felt that Jerry could benefit from facing the reality of his past honestly and openly.  Therefore, although, severing involvement with his parents was one of the first steps Jerry took in dealing with his night terrors, I suggested that he attempt to work through his issues by coming to terms with and confronting his parents about the abuse either directly or in a role play in a session. At a later session, Jerry stated,  "They’re not going to change. My mom is manipulative and my dad wants to believe everything she says. She denied the whole thing and refuses to listen to me anymore." 

As you can see, Jerry did not sever his relationship with his parents to avoid the challenging work he had to do. Jerry severed the relationship only after an attempt to work through his issues. Some clients you treat may not decide to sever family ties, but obviously the decision should always be the client’s decision to make. Regardless of the client’s decision, you can then begin treating the past trauma. What are your current methods for treating trauma? How would you adjust them to benefit a client who suffers from night terrors?

♦ Step #3:  Exploring Present Circumstances
In addition to following sleep guidelines and validating trauma and evaluating family ties, the third step in the psychotherapeutic approach for Jerry was exploring his present circumstances. The purpose of this step is to help night terror clients avoid current abusive relationships. In one of Jerry’s first sessions with me, he talked about his wife Linda. Jerry stated, "My wife is another story altogether. She is either not the woman I married, or really good at pretending to be someone else." 

Subsequently, Jerry identified Linda in his own terms as a ‘rage-a-holic who was incapable of either speaking truthfully or trusting others. Jerry and I discussed possible motivations for Linda’s actions. Jerry added that he didn’t feel Linda’s frequent adultery was something he could continue to live with, either. Jerry and I reviewed some techniques for assertiveness which he later implemented to set boundaries and limits regarding communication with Linda as well as her infidelity. 

Jerry stated, "I think the only thing that really stands between Linda and cheating is opportunity. But I feel like a control freak limiting where she goes and who she sees." How would approach Jerry’s desire to set limits of monogamy? How can you help your Jerry avoid abuse in his or her current relationships?  

♦ Step #4:  Addressing Resultant Health Problems
The fourth step for Jerry was addressing resultant health problems. With Jerry, I decided to introduce him to information regarding the links between trauma, night terrors, and health problems. Jerry found the information to be interesting and pertinent. Jerry stated, "You know, since the night terrors started, I have been getting colds a lot.  I’ve also developed what my doctor calls eczema. I have to deal with skin rashes all the time."

At a later session, after Jerry had dealt with his past and present abuse issues, he stated, "Since my night terrors have started to decrease some, so have my skin problems." Eventually, I agreed with Jerry that no amount of ointment would have eliminated his rashes since they were a byproduct of the emotional stress in his life and his night terror disturbed sleep. What resultant health problems does your client experience? 

♦ Step #5:  Allowing Solitude
In addition to following sleep guidelines, validating trauma and evaluating family ties, exploring present circumstances, and addressing resultant health problems, the fifth step is allowing solitude. As I mentioned earlier, methods of treatment for anxiety disorders can be implemented with clients who suffer from night terrors. With Jerry, it seemed that his way of dealing with his anxiety was staying busy. From morning until night, Jerry kept his schedule full. 

Jerry stated, "My commitment to my job, family, and home, doesn’t leave a lot of time for being idle."  I suggested Jerry take time each day for solitude. Have you found, like I have, that allowing solitude can be a way for clients to recover from emotional wounds? Jerry scheduled at 30 minutes three days a week for spending time in the woods near his home.  Jerry later stated, "Fishing in the river down there really does help recharge me. I just feel guilty sometimes because it seems like I could be getting more done."  How would you help Jerry allow himself solitude?

♦ Step #6:  Implementing the Steps Simultaneously
The last step in this psychotherapeutic approach is implementing the steps simultaneously. For Jerry, progress in the five steps came relatively easy. Jerry implemented the other five steps in order, but later engaged all the steps simultaneously. As you know, throughout the field of psychotherapy, treatment courses are divided into early, middle, and late stages. However, because clients suffering from type B night terrors are generally functional and progress-driven, the first two stages tend to progress quickly with very little resistance. 

For example, Jerry had been overcoming obstacles for his entire life. Therefore, Jerry already believed he had the power to change his behavior and to grow. Think of your client. Would he or she benefit from these six steps like Jerry, or should you use more traditional behavioral interventions?

In this section, we discussed a six step psychotherapeutic approach to treating type B night terrors. The six steps I used with Jerry were following sleep guidelines, validating trauma and evaluating family ties, exploring present circumstances, addressing resultant health problems, allowing solitude, and implementing the steps simultaneously.

In the next section, we will discuss behavioral sleep therapy for children.  For the purpose of this course, this behavioral sleep therapy for children will be explained in two parts.  Behavioral sleep therapy for children consists of initial progression and subsequent progression.
Reviewed 2023

Peer-Reviewed Journal Article References:
Miller, K. E., Micol, R. L., Davis, J. L., Cranston, C. C., & Pruiksma, K. E. (2019). Predictors of treatment noninitiation, dropout, and response for cognitive behavioral therapy for trauma nightmares. Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 122–126.

Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 67–75.

Walters, E. M., Jenkins, M. M., Nappi, C. M., Clark, J., Lies, J., Norman, S. B., & Drummond, S. P. A. (2020). The impact of prolonged exposure on sleep and enhancing treatment outcomes with evidence-based sleep interventions: A pilot study. Psychological Trauma: Theory, Research, Practice, and Policy, 12(2), 175–185.

QUESTION 4
What are the six steps to the psychotherapeutic approach for treating night terrors? To select and enter your answer go to Test.

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