Imagery Rehearsal Therapy for Nightmares: Rewrite a Recurring Dream and Rehearse It

Sketch a recurring nightmare in three simple panels, then redraw it with a new ending. Rehearse the new dream with a calm player and log your nights.

AdultsTeensThoughts & skillsCBT
15–20 minutes, then 10–20 minutes a dayIn person and on video
Free interactive tool
Designed by Michael Thompson, MSc

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For PTSD-related nightmares, start with a clinician.

More

Keep the old nightmare brief and avoid detailed re-living. Screen for sleep apnea and other sleep problems. Children need a caregiver or therapist alongside.

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How to play

  1. Old dream: sketch it in 3 panels with shapes and a few words. Skip it if you like.
  2. New dream: change any panel. Add a helper, a light, a way out, or make the scary thing small.
  3. Under More, give the new dream a name and a few words per panel (optional).
  4. Rehearse: play the new dream, then picture it with your eyes closed, 10 to 20 minutes a day.
  5. See your storyboard. Log your nights now or later, once daily rehearsal has started.

About the technique

Imagery rehearsal therapy treats a recurring nightmare as a learned pattern that can be changed while awake. The client picks a nightmare, changes it in any way they wish, writes or draws the new version, and rehearses the new dream in imagery for a few minutes each day. Barry Krakow and colleagues developed the current form, building on earlier rescripting work (Kellner et al., 1992), and set out the clinical steps in detail; the method does not require recounting the original nightmare at length (Krakow & Zadra, 2006).

The evidence is strong, though not uniform. In a randomized trial with sexual assault survivors with PTSD, imagery rehearsal reduced nightmares and improved sleep and posttraumatic stress symptoms compared with a waitlist (Krakow et al., 2001). A meta-analysis of post-trauma nightmares found large pre-to-post improvements in nightmare frequency, sleep quality and PTSD symptoms, sustained at 6 to 12 months, although the one study with an active control showed small effects (Casement & Swanson, 2012). In a large trial with veterans with chronic PTSD, imagery rehearsal did no better than the comparison treatment (Cook et al., 2010). The American Academy of Sleep Medicine recommends imagery rehearsal for nightmare disorder and PTSD-associated nightmares in adults (Morgenthaler et al., 2018).

It suits adults and, with less direct evidence, teens with recurring nightmares, in session or as daily homework. Keep the old nightmare brief and avoid detailed reliving. For PTSD-related nightmares, start with a clinician who can help manage arousal. Screen for sleep apnea and other sleep disorders that can also disrupt sleep, and keep a caregiver or therapist alongside children.

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For therapists: how to run it

Goal

Replace a recurring nightmare with a new dream you choose, rehearse it daily, and see the nights change.

In session

  1. Introduce the idea first: nightmares are a learned habit, and the brain can practice a new version.
  2. Share your screen or hand over the tablet. Keep the old dream brief: “Just enough so we know which dream it is.” Skip drawing it if that's too much.
  3. Let the client choose the change. Ask: “What would make this dream feel safe or even a bit silly?”
  4. Start rehearsing together with the player, then agree on a daily time to practice for 10 to 20 minutes. Watch distress and slow down if needed.

As homework

  1. Each day, open the link and rebuild or replay your new dream (or use the printed storyboard). Rehearse it for 10 to 20 minutes, not right before bed at first.
  2. Once a week, open the link, rehearse, then tap Next: night log and mark each of the last 7 nights: calm or nightmare, and whether you rehearsed. Nothing is saved between visits, so fill in the whole week in one sitting.
  3. Then tap See my storyboard, then Copy for my therapist, and paste it into your therapist's secure messaging (client portal) or bring it to your next session. Nothing you type is saved, so copy or print before closing.
Good to know

Imagery rehearsal therapy (IRT) changes a recurring nightmare into a new version and has the client rehearse the new version in imagination every day. The client chooses the change; it does not have to be realistic. Keep the old dream brief: shapes and a few words are enough, without the worst details. Nightmares with PTSD, or with loud snoring or breathing pauses (possible sleep apnea), should be checked by a clinician. It is made for adults and teens; with children, a clinician should lead it.

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Behavioral Experiment Worksheet

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Sources & credibility

Method
Imagery rehearsal therapy (IRT) for nightmares
Developed by
Barry Krakow, Robert Kellner, Joseph Neidhardt and colleagues
First described
1992; RCT 2001
Approach
CBT for nightmares
Evidence
Strong research supportRandomized trials and a meta-analysis show large drops in nightmare frequency and better sleep, including with PTSD. The American Academy of Sleep Medicine recommends imagery rehearsal for nightmare disorder.

References

  1. Kellner, R., Neidhardt, J., Krakow, B., & Pathak, D. (1992). Changes in chronic nightmares after one session of desensitization or rehearsal instructions. American Journal of Psychiatry, 149(5), 659–663. Source
  2. Krakow, B. et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with PTSD: a randomized controlled trial. JAMA, 286(5), 537–545. Source
  3. Cook, J. M., Harb, G. C., Gehrman, P. R., Cary, M. S., Gamble, G. M., Forbes, D., & Ross, R. J. (2010). Imagery rehearsal for posttraumatic nightmares: A randomized controlled trial. Journal of Traumatic Stress, 23(5), 553–563. Source
  4. Casement, M. D. & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for post-trauma nightmares: effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical Psychology Review, 32(6), 566–574. Source
  5. Morgenthaler, T. I. et al. (2018). Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. Journal of Clinical Sleep Medicine, 14(6), 1041–1055. Source
  6. Krakow, B. & Zadra, A. (2006). Clinical management of chronic nightmares: imagery rehearsal therapy. Behavioral Sleep Medicine, 4(1), 45–70. Source

How it was made

Built by the Mentalyc team from the original method and the published sources listed here. Nothing you enter is stored.

Questions people ask

How do you make nightmares go away?

For recurring nightmares, imagery rehearsal therapy has good evidence: you change the nightmare's story while awake and rehearse the new version for 10 to 20 minutes each day. Good sleep habits and treating any trauma or stress also help.

How do you do imagery rehearsal therapy for nightmares?

Write or draw the nightmare briefly, change it in any way you like (often the ending), then rehearse the new version daily for 10 to 20 minutes. This tool gives you a three-panel storyboard and a calm rehearsal player.

Do nightmares ever go away?

Many nightmares fade on their own, and recurring ones often respond well to treatment. If nightmares are linked to trauma or are hurting your sleep, it is worth seeing a doctor or therapist.

Is imagery rehearsal therapy effective for PTSD nightmares?

Often, yes. Randomized trials show IRT reduces nightmare frequency and distress, including in PTSD, and sleep medicine guidelines recommend it for nightmare disorder, though one large trial in veterans with chronic PTSD found no advantage over the comparison treatment (Cook et al., 2010). Results usually build over several weeks of daily rehearsal.

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Your game designer
Michael Thompson

Michael Thompson, MSc

Michael's background combines doctoral training in clinical psychology with research on motivation, learning, and emotional regulation.

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Table Of Contents
  1. About the technique
  2. For therapists: how to run it
  3. Worksheets that pair with this tool
  4. Sources & credibility
  5. Questions people ask
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