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Lucid Dreaming as a Treatment for Recurrent Nightmares

Article  in  Psychotherapy and Psychosomatics · February 1997

DOI: 10.1159/000289106 · Source: PubMed

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 Lucid Dreaming and Nightmares 1

Lucid Dreaming as a Treatment for Recurrent Nightmares

Antonio L. Zadra, Ph.D. & Robert O. Pihl, Ph.D.

Department of Psychology, McGill University

Montreal, Quebec, Canada

Dans: Psychotherapy and Psychosomatics, 1997; 66, 50-55.

Address for correspondence:

Antonio Zadra, PhD

Hôpital du Sacré-Coeur
Centre d’étude du sommeil
5400 boul. Gouin Ouest
Montreal (Quebec) CANADA
H4J 1C5

Tel: (514) 338-3013

Fax: (514) 338-2531
e-mail: [email protected]

Running head: LUCID DREAMING AND NIGHTMARES

 Lucid Dreaming and Nightmares 2

Abstract

Background: Lucid dreams occur when a person becomes aware that he or she is dreaming

while still in the dream state. Previous reports on the use of lucid dreaming in the treatment

of nightmares do not contain adequate baseline data, follow-up data, or both. Methods: A

treatment of recurrent nightmares incorporating progressive muscle relaxation, guided

imagery, and lucid dream induction is presented for two case studies. Three other cases

were treated with lucid dream induction alone. The duration of the nightmares ranged from

once every few days to once every few months. Results: The procedures were effective in

all five cases. A one-year follow-up showed that four of the subjects no longer had

nightmares and that one subject experienced a decrease in the intensity and frequency of her

nightmares. Conclusions: The alleviation of recurrent nightmares in these five cases

parallels the results reported by other authors who have used training in lucid dreaming to

treat nightmares. Our results support the idea that treatments based on lucid dream

induction can be of therapeutic value. Based on these and other case studies, it remains

unclear whether the principal factor responsible for the alleviation of nightmares is lucidity

itself, or the ability to alter some aspect of the dream.

Key words: dream; lucid dreaming; nightmare; imagery; psychotherapy.

 Lucid Dreaming and Nightmares 3

Approximately 5% to 7% of adults report a current problem with nightmares [1, 2].

More recent studies indicate that the prevalence of nightmares may be considerably higher

[3, 4]. Though the prevalence of recurrent nightmares has not been specifically investigated,

their occurrence has been documented in a variety of individuals including otherwise normal

clients [5, 6], victims of sexual assault or abuse [7, 8], psychosomatic patients [9, 10], and

war veterans [11, 12]. Recurrent nightmares are also considered as a diagnostic sign of

post-traumatic stress disorder [13]. In addition, many people who report frequent

nightmares also report recurrent nightmares [14, 15].

Several authors have suggested that lucid dreaming may be clinically useful,

particularly in the treatment of nightmares [16, 17, 18]. Lucid dreams occur when a person

becomes aware that he or she is dreaming while still in the dream state. Some lucid

dreamers report recall of events from their waking life (i.e., their memory remains intact),

the ability to reason, and control of their dream bodies as desired. Furthermore, some lucid

dreamers can change the dream scenery at will. Lucid dreaming is a learnable skill [19, 20]

and it is now known that lucid dreams occur during unequivocal REM sleep [21, 22]
The use of lucid dreaming in the treatment of nightmares has been previously reported

[18, 23, 24, 25]. However, the two case studies presented by Halliday [23, 24] do not

contain follow-up data, and none of the three case histories presented by Tholey [18]
contains baseline data and only one contains follow-up data. In this paper, we suggest

mechanisms through which lucid dreaming may operate to reduce the frequency and

intensity of nightmares, describe how lucid dreaming was used to treat nightmares, and

provide baseline and follow-up data for five case studies.

Lucid dreaming may operate through a number of mechanisms to achieve positive

therapeutic outcomes. In his review of psychological therapies of nightmares, Halliday [26]

suggested four distress-producing factors for nightmares: their believed importance, their

dreadful and anxiety producing story line, their perceived realism, and their

uncontrollability. By becoming lucid in one's nightmare, an individual may directly affect

three of these four factors. Specifically, achieving lucidity within a nightmare can allow a
 Lucid Dreaming and Nightmares 4

client to: alter the anxiety producing story line by consciously modifying the content of the

nightmare, realize that the experience is a dream and not a real event taking place in the

physical world, and choose the manner with which to respond to and interact with the

dream imagery, thus reducing the nightmare's uncontrollability. Becoming aware during a

nightmare that the experience "is only a dream" may also reduce its perceived importance.

LaBerge and Rheingold [27] have suggested that expectations can play an important

role in dream construction, so that what a person expects to happen next in a dream often

influences or determines the manner in which the dream will unfold. It is possible that

individuals who suffer from recurrent nightmares may be locked into a fixed way of

responding to the nightmare's imagery and of anticipating what will happen next. This in

turn leads the dreamer to re-experience the same threatening imagery. Lucid dreaming may

provide recurrent nightmare sufferers with new responses and expectations concerning the

nightmare's progression, thereby altering the repetitive nature of such nightmares.

Treatment

Subjects are first trained in progressive muscle relaxation [28]. Once subjects are
relaxed, they rehearse (i.e., imagine) their recurrent dream in as much detail as possible
while describing it to the therapist. The therapist guides this rehearsal, for example, asking
about various elements in the dream or bringing particular details to the subject's attention.
The subject then selects a part of the recurrent dream which is emotionally and/or visually
salient, and during which he or she can imagine carrying out a particular task. The subject
imagines performing this task in the dream while saying that he or she is dreaming. Later,
during an actual dream, this action will cue that the experience is a dream. Typically, this
task is as simple as looking at one's hands. Once the relaxation and imagery exercises have
been completed, subjects are instructed to practice them at home, especially just before
going to sleep.
The rationale for this treatment is as follows: by repeatedly rehearsing the recurrent
dream together with a task which is intentionally carried out at a pre-selected salient point in
the dream, the subject will remember to carry out the task when the recurrent dream occurs.
The task serves as a pre-rehearsed cue to remind the subject that the experience is a dream.
 Lucid Dreaming and Nightmares 5
At this point, the subject is dreaming lucidly and can determine a different course for the
dream content.

The therapist consults with the subject to find an appropriate way to modify the

recurrent nightmare once lucidity is achieved. Various approaches include Garfield's [29]

suggestion to "confront and conquer" the feared scene, Halliday's [23, 24] suggestion to alter

some small aspect of the dream, and Tholey's [18] suggestion to have the dream ego engage

in conciliatory dialogue with hostile dream figures.

Case Reports

Three of the five subjects were referred by colleagues familiar with the authors’

research interests. Two subjects were participants in a dream study who had expressed a

desire to receive treatment for their nightmares. All met DSM-III-R criteria for the

diagnosis of dream anxiety disorder (nightmare disorder). None of the subjects had received

prior treatment for their nightmares nor had any been in psychotherapy. The subjects were

instructed to keep a written record of any nightmares they had, as well as of dreams that they

felt resembled any aspect of their nightmares, for a minimum of five weeks following the

treatment.

Case 1. A was a 52-year-old Italian homemaker who came to Canada in 1957. She reported

experiencing the same nightmare for over twenty years with a frequency ranging from once

a week to once every several months. As a young child, during the second world war, she

had witnessed several bombings. The nightmare consisted of being in her home in Canada

when loud sirens were heard. She would begin to panic and to look for her two children.

Finding herself in the kitchen, A would look through the window and see a bomber that

appeared to be headed straight for her home. She would then hide beside the window while

calling frantically for her children. The plane would stop by the kitchen window and the

pilot would peer into the home looking for her and her children, presumably to kill them. At

this point in her dream, she would wake up.

During the guided imagery, a target point in the dream was selected when A was to look

at her hands. This was to occur at the moment in which the pilot looked into the window,
 Lucid Dreaming and Nightmares 6

since this was the most emotionally salient part of her dream. A discussion was then

undertaken to determine what she would like to do in her dream if she became lucid. She

decided that she wanted to confront the pilot and command the scenery to disappear.

Because of the strength of A’s religious convictions, she suggested that she use the phrase

"In the name of God, I command you to go away."

Four weeks after the treatment, the subject twice experienced her recurrent nightmare.

On the first occasion, the nightmare was experienced as usual. On the second occasion, A

successfully remembered to look at her hands and became lucid. When she said "In the

name of God I command you to go away," the dream scenery shifted and she found herself

in a church that she had attended in Italy. She reported that a powerful feeling of both joy

and peace accompanied the change in dream content.

This client’s progress was followed at six-month intervals over a two year period.

During this time, she did not have a recurrence of her nightmare, though three unrelated

anxiety dreams were reported. In addition, she reported having had several lucid dreams

which she described as being highly pleasurable.

One of her anxiety dreams is noteworthy in that a particular element of the treatment

(i.e., looking at her hands) re-occurred, albeit in a different manner. In this dream, her

brother's feet had somehow become stuck on a railway track. A train was quickly
approaching and both the client and the dream character became extremely agitated. When

the train was no more than a 100 meters away, she raised her hands and yelled "Stop!" At

that moment, the train came to a halt and thus was prevented from hitting her brother. At no

point in this dream did A realize that she was dreaming. She explained that she noticed her

hands while trying to rescue her brother, and that something made her realize that her hands

contained some sort of magic or power.

At a four-year follow-up the client reported no further nightmares.

Case 2. B was a 43 year-old female who had quit her job due to major depression. The

depression resulted from the suicide of her 21 year-old son, whose body she had found in

the basement of her home. The depression had persisted for two and a half years, and the
 Lucid Dreaming and Nightmares 7

client refused to take any medication for her condition. B also harbored intense feelings of

guilt over not having "felt" that her son's suicide was about to happen.

Over a seven to eight month period following this tragedy, B experienced frequent

nightmares with varying content. These nightmares typically involved situations related to

the suicide, such as finding her son's body or having the paramedics arrive. After eight

months, a particular nightmare began to recur to the exclusion of her other nightmares. The

nightmare was reported as occurring once a week on average, and was sufficiently anxiety

provoking to cause her to awaken. At the time of treatment, the nightmare had been

occurring for close to three years.

The nightmare was described as follows: the client is in the living room of her home

when she notices her son walking by on the sidewalk. She begins to yell his name and

pound on the windows, but he does not appear to notice and continues walking. She then

runs out into the street screaming his name, but her son is nowhere in sight. At this point,

she wakes up.

During the guided imagery exercise, B recalled having sometimes seen a mansion in her
dreams which was located near her own home but which did not really exist. When asked if

she thought anyone lived in the mansion, she answered that she didn't know but that maybe

that was where her son was going. The suggestion was made that she might want to go into
this house and find out who lived there. B agreed to this suggestion, and a target point in the

dream was selected for her to become lucid. She was instructed to pay attention to her

hands and to look at them when she found herself pounding on the windows in her dream.

During the second week that followed the session, B reported having had her recurrent

nightmare on two consecutive nights. On neither occasion did she become lucid. An

interesting development occurred, however, on the second night. After B had run out onto

the street looking for her son, she noticed the mansion and remembered that she was

supposed to see who lived there. She went up to the house and rang the doorbell. A

beautiful young lady wearing a white gown answered the door. B asked if her son was

inside and the lady took her by the hand and led her to a room. At that moment, the lady
 Lucid Dreaming and Nightmares 8

spoke for the first time and said simply, "Your son is in here." B opened the door and found

the room to be filled with white flowers. She was deeply moved and woke up shortly

thereafter. It is interesting to note that B never actually became lucid in her dream. What

she did do, however, was remember that it was important for her to go to the mansion.

B was contacted for a six-month follow-up. She reported that since the "white flowers"

dream, she had not experienced any type of nightmare, nor had she ever become lucid in one

of her dreams. A one-year follow-up showed that her depression had lessened, and that she

was still free of nightmares.

The treatment reported in the previous two cases is eclectic, and contains approaches

found in several other treatments. Although this treatment does not involve the standard

procedure of formally constructing hierarchies of disturbing dream images, it nevertheless

shares some similarities with desensitization and other behavioral procedures. Two

controlled studies have demonstrated the therapeutic effectiveness of such approaches in

treating nightmares [15, 30]. This technique also bears some resemblance to what Halliday

[26] has termed story line alteration procedures, in which an attempt is made to change some
aspect of the nightmare content, typically through waking imagery exercises. This approach

has also been shown to be effective [31 - 34].

Given the findings described above, we cannot say which of the elements (or
combinations) of our technique were most useful in alleviating the nightmares. To address

this issue, the efficacy of lucid dream induction alone was assessed in three case studies,

which are presented below. Progressive muscle relaxation was not used with these subjects,

while guided imagery was used only insofar that they were asked to practice visualizing

themselves becoming lucid in their nightmares and carrying out a prescribed task.

Case 3. C was a 35-year old divorced woman who presented with a complaint of life-long

nightmares. Since approximately the age of 16, her nightmares consisted primarily of

dreams in which she was being chased by a mob who killed and mutilated everyone they

caught. The client herself had never been caught by her pursuers and would wake-up while

hiding (e.g., behind buildings, barrels, or in wooded areas) with the mob closing in on her.
 Lucid Dreaming and Nightmares 9

The nightmares were reported as occurring from several times a week to once every two to

three weeks. Because C would sometimes re-experience or “continue” her nightmare when

returning to sleep, she would often avoid falling back to sleep after awakening from a

nightmare.

The most salient part of her nightmare was described as when she would be hiding,

often with several mutilated corpses nearby. She was instructed to associate her hiding with

the fact that she was dreaming and to imagine herself clenching her fists. C stated that she

did not want to attack or kill her pursuers but rather try to talk to or confront one of her

pursuers. Several strategies for interacting with these characters were discussed.

That very same night the client had her nightmare but awoke early in the dream. The

nightmare reoccurred the following week. In this dream, she was hiding when she heard

one of the pursuers approaching. Though she did not realize that she was dreaming, she

stepped out and yelled, “I’m not going to hide anymore! Who am I?” Her pursuer replied

in an enthusiastic tone that she was the person they had been looking for all this time and

went to explain the geographical importance of the area . While he was talking, C heard
someone yell “Cut!” Looking around her she realized that she was on a large movie set,

complete with cameras and lighting equipment. Her pursuer walked over to her, gave her a

hug, and said, “Good job.” C was somewhat confused and the movie director came over and
talked to her about her acting, but she could not remember the details upon awakening.

A six-month and 1-year follow-up showed that the client’s nightmares had decreased in

frequency, occurring once every five to six weeks. Moreover, the nightmares were

described as being much less intense and frightening than they had been before the

intervention, and they no longer involved dead or mutilated bodies. In addition, C reported

that she was no longer afraid of returning to sleep after awakening from a nightmare. At a

two-year follow-up the subject reported no further nightmares.

Case 4. D was a 22 year-old undergraduate who had a recurrent nightmare with a frequency

ranging from once a month to several times per week. D had begun to experience her

nightmare sixteen months prior to treatment, following the accidental death of her uncle. In
 Lucid Dreaming and Nightmares 10

this nightmare, D arrives home from school and notices an ambulance in the driveway. In

her house there is much commotion: people she does not know talking loudly and giving

orders, her mother crying, and paramedics carrying a body on a stretcher covered by a white

blanket. Oddly, one of the living room walls is dark red in color. She panics, asking people

what has occurred, and someone mentions that her uncle is dead. She exclaims, "It can't be!

It can't be!" and runs upstairs. There she discovers other unknown characters who are

passing

various documents back and forth. At that moment, D runs back downstairs to see the body

and talk to her mother, whereupon she awakens.

After she described her nightmare, D was told to form an association between the red

living room wall and the fact that she was dreaming. She was also told to think of this

association at night before going to sleep. If she became lucid during her nightmare, D was

to close her eyes and imagine the living room wall being white (its true color) and to tell

herself that the wall would be its usual color once she re-opened her eyes in her dream.

One and a half weeks after the session, D had her nightmare and became lucid as soon
as she saw the red wall. She remembered that she was to try to change the wall's color but

awakened after having stared at the wall for several seconds. Three weeks later, she again

reported having become lucid during her nightmare. D successfully closed her eyes and
imagined the wall being white. Once she re-opened her eyes she saw that the living room

wall had in fact changed from deep red to white. At that point, she decided to leave the

house and told one of the paramedics "He's not really dead. It's just a dream.", to which he

replied "I guess we should all get on with our lives then." Once outside, D noticed that the

ambulance was no longer there. She began to walk down her street and admired various

cloud formations in the sky.

D stated that she was surprised by the fact that she was able to change this anxiety

dream into such a pleasant one, especially the part with the clouds. She also reported that

the experience had increased her self-confidence, and that she felt she had more control over

her future than she had initially believed.

 Lucid Dreaming and Nightmares 11

D was contacted for a six-month and one-year follow-up. On both occasions she

reported neither a recurrence of her nightmare, nor any new anxiety dreams.

Case 5. E was a 42-year-old married man. He complained of nightmares in which he would

lose control of his car while driving down steep mountain roads. Invariably, he would

awaken as his car was about to crash or fall over a precipice. E had never driven on

mountain roads in actual life nor had he ever been involved in a serious car accident. The

nightmares were not recurrent in that the specific content of the nightmare would vary from

one time to the next. For instance, he would lose control of his car for a variety of reasons

including brake failure, coming to an unexpected hairpin turn, or while trying to avoid

obstacles such as small animals or debris. E reported that the nightmares had begun in his

mid-twenties and that they occurred from two times a week to once every two to three

months.

E recalled having had numerous flying dreams as a child. He decided that if he became

lucid during his nightmare, he would make his car fly over the mountains. He was

instructed to form an association between driving in mountainous terrain and the fact that he
was dreaming and to imagine himself saying the work “Fly!” while driving down the

mountains.

Two weeks after the session, E had a dream in which he was speeding down a long and
twisty road when he had to avoid a large rock that had fallen onto his lane. Unlike his usual

nightmares however, he was able to maneuver his car around the obstacle without loosing

control of his vehicle. A few days later, E dreamt that he was driving relatively slowly up a

steep mountain road and became aware that he was dreaming. He then accelerated and

when he reached the top of the mountain willfully drove his car off a cliff with the intention

of making it fly. The car did not gain much altitude and soon began to fall towards a large

body of water. However, E reported that he wasn’t frightened and that the car dropped

slowly and in a pleasant way. E also told himself that since this was a dream, there was no

reason why his car could not float on the water. Once the car hit the water, he pressed

down on the accelerator and the car began to travel much like speed-boat gaining
 Lucid Dreaming and Nightmares 12

tremendous speed. E noted that this dream had been exhilarating. In the four weeks that

followed this dream, the client had two lucid dreams, an uneventful dream in which he was

driving in the countryside, and no nightmares or anxiety dreams.

Six months after the initial treatment session, E was still free of nightmares and

continued to have an occasional lucid dream. These gains were maintained at 1-year and

18-month follow-up.
Discussion
The alleviation of recurrent nightmares in these five cases parallels the results reported

by other authors who have used training in lucid dreaming to treat nightmares [18, 23, 24,

25]. Our results support the idea that treatments based on lucid dream induction can be of

therapeutic value. Even in the two cases (i.e., B and C) where dream lucidity was not

achieved, the subjects clearly incorporated elements from the lucidity rehearsal exercises

into their nightmares with positive results.

Several features of the treatment are noteworthy. Lucid dreaming allows the subject to

interact with the nightmare in a creative fashion while in the dream. As discussed by Tholey

[18], the ability to become lucid in one's anxiety dreams can lead to important insights for

both the client and the therapist. Though the treatment was originally designed for recurrent

nightmares, cases 3 and 4 suggest that it can be used successfully in the treatment of

nightmares with differing contents across occurrences. Finally, as was reported by C, dream

lucidity can give rise to positive psychological elements which carry over into waking life.

Similar effects have been reported by Tholey [18] and Brylowski [25].

Based on these and other case studies, it remains unclear whether the principal factor

responsible for the alleviation of nightmares is lucidity itself, or the ability to alter some

aspect of the dream. In the cases of B and C, remembering to perform a certain action in

their nightmare resulted in a positive outcome. Though neither of them became lucid during

their nightmare, elements from the training in lucid dreaming were clearly incorporated into

the nightmare. One of the dreams reported by A raises a similar point. In this non-lucid

dream, A felt that her hands contained some sort of magic or power, and successfully used
 Lucid Dreaming and Nightmares 13

this power to stop a train from hitting her brother. Conversely, both Halliday [24] and Zadra

[35] have reported case studies in which lucidity without the element of control actually

worsened the nightmare. Based on these cases, we suggest that a crucial aspect in the

treatment of recurrent nightmares is the dreamer's ability to alter some detail in the

otherwise repetitive dream. The client's ability to affect the nightmare's uncontrollability,

either through new responses or altered expectations during the dream, may represent a key

element in the elimination of nightmares. This reasoning agrees with Halliday's [24]

suggestion that such case studies "may imply that therapy should sometimes aim for control

rather than just lucidity per se." However, given the limited number of case studies that

have appeared in the literature to date, an adequate understanding of the relative importance

of dream lucidity versus dream control requires further investigation.

Although case studies can provide some information, what is clearly required are

controlled treatment studies in which the therapeutic benefits of treatment elements can be

separately evaluated. One study has shown that use of muscle testing (‘psychological

kinesiology’) in guiding dream interpretation is effective in reducing the frequency of

recurring dreams [36] Similarly, five studies have demonstrated the effectiveness of

cognitive-behavioral interventions such as relaxation, desensitization, and imagery rehearsal

in the treatment of nightmares [15, 30 - 33]. However, in addition to data on nightmare

frequency, it would be useful for future studies to evaluate pre- to post-treatment changes in

the content of nightmares and related dreams. Such data may help clarify differential effects

of these various treatment approaches. For instance, it is possible that these approaches alter

different aspects of nightmare content such as the setting, emotional intensity, time of

awakening, or the dreamer’s response to the dream content. Miller and Dipilato [15] noted

that some of their subjects reported a decrease in the frequency of their nightmares

subsequent to treatment, but when the nightmares did occur, they were experienced as being

more intense than prior to treatment. In addition, the authors noted that some of their

successful clients reported dreams with content similar to that of their old nightmares, but

were no longer calling such dreams “nightmares.” It is possible that some treatments alter
 Lucid Dreaming and Nightmares 14

client’s conscious attitudes towards their nightmares rather than nightmare content per se.

Objective dream content scales have been used successfully in the study of recurrent dreams

and their relation to psychological well-being [37] and could be particularly useful in

evaluating differential treatment effects. As discussed by Gottschalk [38], it also remains to

be determined if as a result of receiving treatment, clients actually stop having nightmares,

continue to have nightmares but do not recall them, or intentionally suppress their reporting.

Finally, as noted by Kellner et al. [32], non-specific factors such as disclosure, placebo

effects, and exposure to the nightmares in the waking state may contribute to observed

reductions in nightmare frequency and associated distress. Furthermore, there is some

evidence to indicate that simply recording one’s nightmares can lead to a decrease in

nightmare frequency [31]. The relative importance of such factors and their mode of action

in decreasing the frequency of nightmares remains unknown.

 Lucid Dreaming and Nightmares 15
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