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 details on IRT, including how it works, why it helps, and how to try it for yourself.
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.
At home, you’ll rehearse this ending for anywhere from 10 to 20 minutes each day — while you’re awake, of course. Your therapist may offer a more specific rehearsal 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 PTSD-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. By the end of the study, they reported significantly fewer nightmares — with no adverse effects — than those who received the usual treatments.
IRT can help treat:
- nightmares that don’t seem to have any specific cause
- PTSD-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.
When you wake up after a nightmare, you might be alone, or at least the only one awake. But in an IRT session, you have a therapist to offer support. As you repeatedly expose yourself to the nightmare while practicing relaxation exercises, your brain gradually learns to respond to the nightmare content with a calmer state of mind.
Here’s another way of thinking about it: As you repeatedly discuss the dragon you keep dreaming about, it may feel less like a mysterious horror and more like a large lizard you’ve talked about ad nauseam.
Another mechanism at work? The sense of mastery you gain. Nightmares might feel so scary in part because they seem like a terror you have to endure instead of an experience you can control.
Rewriting the ending, then, can give you a sense of agency and power. When your waking self imagines your sleeping self solving the problem in your dream, you unlock another possibility for your brain to grasp. The more you imagine a happy ending, the easier it becomes for your brain to switch to that more pleasant path mid-dream.
Here’s an in-depth exploration of how IRT might address that dragon nightmare:
Say you keep dreaming a dragon is chasing you through the walls of your old school. No matter how fast you run or where you try to hide, it always catches up and eats you.
In the session, you tell the therapist your dream in as much detail as you can. The therapist may then ask about your memories of school:
- Did you struggle in certain classes?
- Did your teachers discipline you a lot?
- Did other students bully you?
- How did you feel about school overall?
Well, now that they ask, the dragon’s voice does sound a lot like the voice of the kid who bullied you. After you share this with your therapist, the two of you discuss how the bullying affected you and how you feel about it now. Maybe you wish you’d told someone about the bullying or spoken up for yourself.
You and the therapist can then work to write an ending to the dream that ties in these feelings. The dream begins with the dragon chasing you through the halls. But instead of helplessly becoming the dragon’s dinner, you might:
- summon heroes to help you tie up the dragon
- grab a weapon and slay the dragon yourself
- yell at the dragon until it leaves you alone (one of Marks’ clients used this solution to banish his nightmare monster)
It’s your dream, so you can get creative with the ending.
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 tend to feed into your sense of helplessness. They can easily get railroaded into the original bad ending. Proactive endings tend to stick better in the mind.
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.
Participants who had nightmares a couple of times a month often completely eradicated their bad dreams. Participants who had nightmares on a weekly basis didn’t stop having nightmares completely, but they often had far fewer bad dreams after IRT.
In short, if you have nightmares twice a week, IRT could help 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.
You could experience some distress when recounting your nightmares during a therapy session, particularly if your nightmare has roots in a traumatic experience. Adjusting your rehearsal technique, with help from your therapist, can usually help ease feelings of anxiety and distress.
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.
That said, this doesn’t appear to happen often — no other studies have reported a similar outcome.
If you want to try it on your own, keeping these tips in mind can help:
- Work on one nightmare at a time.
- Practice one solution at a time. Use the solution for a week or two before switching to a different scenario.
- Keep the alternative ending simple and easy to remember.
- Write an ending that helps you act on the problem instead of avoiding it. (In short, creating a “dream closet” to hide in may not help.)
If trying IRT by yourself feels too stressful, or you have a hard time getting the results you want, consider working with a sleep psychologist for extra support.
Nightmares often go untreated. In fact, less than 38% of people with clinically significant nightmares ever seek professional help.
Many people don’t realize treatment actually exists for nightmares — treatment that doesn’t require participation in a long, intensive sleep study. But IRT treatment is typically very brief, and you can even do it remotely.
If you’d like to try IRT from a trained professional, you can:
- ask your primary care doctor or another 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 your nightmares stem from trauma or happen with mental health conditions like PTSD or depression, working with a therapist to address symptoms could help reduce nightmares and improve your sleep.
Many sleep experts consider IRT the go-to treatment for nightmares, and for good reason: It’s versatile, effective at reducing symptoms, and has a low risk of side effects.
You can even try IRT on your own. If the process feels intimidating, then you may want to work with a therapist, at least to start.
You don’t have to accept nightmares as a fact of life. IRT can help you flip the narrative in your dreams and make your sleep feel safe again.
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.