Rewrite a Recurring Nightmare in 5 Steps, the Way Sleep Clinics Do It

Rate your recurring dreams from 0 to 10 for fear and start with one near 3. Starting mild is a common suggestion, so the skill is learned on gentle material before anything heavy arrives.

Barry Krakow and colleagues tested the method in New Mexico between 1995 and 1999. In the JAMA trial published in 2001, 168 women with chronic nightmares and sexual-assault-related PTSD were randomized to three sessions of imagery rehearsal therapy (88 women) or a wait-list (80). Treated women reported fewer nightmares, better sleep and lower PTSD scores at 3 and 6 months, though 114 of the 168 completed follow-up.

The five steps

1. Choose a milder recurring nightmare. Around 3 out of 10 on fear. A flashback to something that actually happened is not material for a worksheet.
2. Write it down in the present tense. Setting, people, what happens. Half a page is plenty.
3. Change it however you want. The ending, the place, who is there, what you can do. It can be absurd. A dream about being chased can end with the chaser tripping over a garden hose and apologizing.
4. Write the new version. Include enough detail that you could close your eyes and see it from start to finish.
5. Rehearse it for 10 to 20 minutes a day. Read it, then picture it. Earlier in the evening tends to suit people better than lying in bed. Give it a few weeks, then take the next nightmare. A rewritten dream also changes how the next morning starts, a link explored in reader questions on dream content and mood.

What the trials do and do not support

A self-run version has its own evidence. In a 2010 paper in the International Journal of Dream Research, Jaap Lancee, Victor Spoormaker and Jan van den Bout randomized 278 people to self-help imagery rehearsal, two expanded versions, or a waiting list, and the plain imagery-rehearsal version was the only one that clearly beat the waiting list. Only 73 participants completed every questionnaire, and the authors urged caution because of low power and heavy dropout.

Waiting lists flatter any treatment, so those wins are weaker than they sound, and sleep loss is a plausible complication, since REM rebound nights can intensify dreams (an inference, not a trial result). The drug route has a record of its own: the 2018 New England Journal of Medicine trial of prazosin in 304 veterans (Raskind et al.) found no benefit over placebo for distressing dreams, although the American Academy of Sleep Medicine’s 2018 best-practice guide still lists it as an option beside recommending imagery rehearsal. Nightmare disorder is a clinical condition in that guide. Dreams that follow trauma, come most nights or wake someone in terror belong with a clinician, who can run the same technique with support.

Common questions about the technique

Does imagery rehearsal therapy work for nightmares?

In Krakow and colleagues’ 2001 JAMA trial, 168 women with sexual-assault-related PTSD were randomized and 114 completed follow-up; the three-session treatment cut nightmares and improved sleep and PTSD scores against a wait-list, and an intent-to-treat analysis held up. Whether it beats an active comparison treatment is less settled.

Can I do it myself from a worksheet?

Partly. Lancee, Spoormaker and van den Bout randomized 278 people to self-help versions in 2010, and plain self-help imagery rehearsal was the only version that clearly beat the waiting list, though only 73 participants completed every questionnaire and the authors warned about low power.

Is a drug a better first move for PTSD nightmares?

The 2018 NEJM trial of prazosin in 304 veterans (Raskind et al.) found it no better than placebo for distressing dreams. The American Academy of Sleep Medicine’s 2018 best-practice guide still lists prazosin as an option and recommends imagery rehearsal, so the choice is a conversation with a prescriber.