Imagery rehearsal therapy (IRT) is a form of cognitive behavioral therapy (CBT) used specifically to help improve your sleep by addressing nightmares. In fact, it’s the most frequently recommended therapy technique for severe nightmares.
Nightmares fall into two main categories: post-traumatic nightmares and idiopathic nightmares.
Post-traumatic nightmares happen after trauma or a frightening event. Idiopathic nightmares have no clear cause.
No matter the underlying cause, nightmares can cause a lot of distress, not to mention disrupt your rest and leave you still exhausted when you wake up.
Evidence suggests between 3% and 8% of people have more than one nightmare a week. And though it might go without saying, having nightmares on a regular basis can make it tough to get a good night’s sleep.
But IRT could be the key to better dreams. Developed in 1978 by psychiatrist Isaac Marks, this approach has you recount your nightmare while awake so you can create a happier alternative ending. You mentally rehearse this new ending every day with the idea that the nightmare will change in your sleep.
Read on for more information on how IRT works, why it works, and how to try it.
IRT sessions last between 60 and 90 minutes.
During your session, you’ll recount your most common recurring nightmare with a therapist. After you and your therapist discuss the possible stressors or traumas feeding the dream, you’ll brainstorm an alternative ending.
You can rehearse this ending for anywhere from 10 to 20 minutes each day at home. Your therapist may give you a specific time frame.
By the end of 2 weeks, your nightmare will likely become less frightening, if it doesn’t disappear entirely. Further sessions can help you troubleshoot any concerns that come up or address additional nightmares, but not everyone needs multiple sessions.
If you have idiopathic nightmares, you may need only one or two sessions with a therapist. Nightmares occurring alongside post-traumatic stress disorder (PTSD) tend to be more severe, so they may take longer to treat.
IRT for Post-traumatic stress disorder-related nightmares.
A small study from 2018 compared a CBT/IRT intervention with usual care (therapy and medication) for 22 veterans.
Half of the participants received six sessions of CBT/IRT, with a session every other week for 12 weeks. They reported a reduction in nightmares with no adverse effects, compared to those who received the usual treatments.
IRT can help treat.
- “There are nightmares that don’t seem to have a cause.”
- Post-traumatic stress disorder-related nightmares.
- Depression-related nightmares.
IRT can reduce nightmare frequency and in-dream anxiety that happens with any type of nightmare. Its benefits appear strongest for idiopathic nightmares, but it still has a noticeable impact on PTSD- and Depression-related nightmares..
This matters because 30% of people with psychiatric conditions have nightmares. Nightmares can disrupt sleep and increase stress levels, effects that often worsen your other symptoms. If IRT can reduce nightmares and improve your sleep, other mental health symptoms may improve, in turn.
A process called desensitization helps explain why IRT can make your nightmares less terrifying.
You might be alone or the only one awake when you wake up after a nightmare. In an IRT session, you have a therapist to help you. As you expose yourself to the nightmare while practicing relaxation exercises, your brain learns to respond to the nightmare in a calmer state of mind.
It may feel less like a mystery and more like a large lizard if you keep dreaming about it.
“Another mechanism is working? The sense of mastery you gain. It’s possible that nightmares feel like a terror because you have to endure it.”
Rewriting the ending can give you a sense of power. When you imagine your sleeping self solving a problem in your dream, it opens up another possibility for your brain. The more you imagine a happy ending, the easier it is for your brain to switch to a more pleasant path.
IRT might address the dragon nightmare.
You keep dreaming that a dragon is chasing you through the school. It always catches up to you no matter how fast you run or how far you hide.
In the session, you tell the therapist your dream in detail. The therapist may ask about your school memories.
- Did you struggle in some classes?
- Did your teachers discipline you?
- Did other students bully you?
- What did you think about school?
“The dragon’s voice sounds a lot like the voice of the kid who bullied you. After you share this with your therapist, they will discuss how the bully affected you and how you feel about it now. Maybe you should have told someone about the harassment.”
“You and the therapist can work on a dream ending to tie in the feelings. The dream begins with a dragon chasing you. You might instead become the dragon’s dinner.”
- You need to summon heroes to help tie the dragon.
- You can slay the dragon with a weapon.
- yell at the dragon until it leaves you alone (one of Marks’ clients used this solution to banish his nightmare monster)
It is your dream and you can make it your own.
Just know your therapist will probably recommend you choose an active solution to confront the threat instead of a passive solution, like hiding.
Passive solutions can feed into your sense of being powerless. They can easily get railroaded into the bad ending. It is better to have proactive endings.
Out of all the therapies for nightmares, IRT has the most supporting evidence.
- Nightmare frequency: Participants reported an average of one fewer nightmare per week.
- Nightmare distress: Their distress levels fell to nearly half of the pre-treatment levels.
- Insomnia severity: Their insomnia severity scores decreased by about a third.
A 2021 study with 28 participants showed similar results. More than 3 out of 5 participants experienced fewer nightmares, though this depended on how common their nightmares were in the first place.
People who had nightmares a couple of times a month were able to completely eliminate their bad dreams. People who had nightmares on a weekly basis, but stopped completely, had fewer bad dreams after IRT.
If you have nightmares twice a week, IRT could help you cut this down so you only experience nightmares a few times a month.
Once you master IRT techniques, the benefits can stay with you for a long time. Study follow-ups have shown the benefits of IRT often last for years after the original treatment.
According to a literature review by the American Academy of Sleep Medicine (AASM), negative effects from IRT remain quite rare.
If your nightmare has roots in a traumatic experience, you could experience some distress when you retell your nightmares during therapy. Adjusting your rehearsal technique can help ease your anxiety.
The review authors did note one potential side effect, though: Two participants from one study reported that although they had fewer nightmares after IRT, the nightmares they did have became more distressing.
No other studies have reported a similar outcome.
Keeping these tips in mind can help you try it on your own.
- Work on one nightmare at a time.
- Practice one solution at a time. Before you switch to a different scenario, use the solution for a week or two.
- The alternative ending should be simple to remember.
- The ending you write should help you act on the problem. Creating a closet that is a dream closet may not help.
“If you’re trying IRT alone and it’s hard to get the results you want, you should consider working with a sleep psychologist.”
Nightmares often go untreated. In fact, less than 38% of people with clinically significant nightmares ever seek professional help.
“Many people don’t realize that treatment for nightmares doesn’t require participation in a sleep study IRT treatment is usually very brief, and you can do it remotely.”
If you want to try IRT, you can get help from a professional.
- Ask your doctor or other healthcare professional for a referral.
- do an internet search for local sleep specialists or psychologists who offer IRT
- check AASM’s directory of sleep centers
If you have nightmares that are related to trauma or mental health conditions like depression, you should work with a therapist to improve your sleep.
IRT is the go-to treatment for nightmares because it is versatile, effective at reducing symptoms, and has a low risk of side effects.
You can try it on your own. If the process feels intimidating, you may want to work with a therapist.
“You don’t have to accept nightmares as a fact of life. IRT can help you make your dreams more vivid and make you feel more safe in your sleep.”
Emily Swaim is a freelance health writer and editor who specializes in psychology. She has a BA in English from Kenyon College and an MFA in writing from California College of the Arts. In 2021, she received her Board of Editors in Life Sciences (BELS) certification. You can find more of her work on GoodTherapy, Verywell, Investopedia, Vox, and Insider. Find her on Twitter and LinkedIn.