One of the most dramatic, butt-kicking examples of an effective new treatment tool for posttraumatic stress is a simple protocol called Nightmare Reprocessing, devised by two V.A. psychologists, Edgardo Padin-Rivera and Beverly Donovan at the Louis Stokes Cleveland V.A. Medical Center.
From all indications, when this method is followed, trauma survivors can rid themselves of a repeating nightmare in three weeks or less.
Experienced therapists will find this hard to swallow. I know I did. This is because traditional, deep dish, insight-based therapy doesn't get a whole lot of traction with repetitive nightmares.
And, to add insult to injury, Nightmare Reprocessing is a simple procedure that any idiot can follow. (Sorry, colleagues! I didn't like it either!) It doesn't require savvy training, deft insight or masterful technique. You just follow the steps... which I'll describe in a minute.
Drs. Padin-Rivera and Donovan developed their iteration by tweaking Barry Krakow's Imagery Rehearsal Therapy, which you may have read about last fall in the New Yorker. They added some clever elements from Francine Shapiro's EMDR (Eye Movement Desensitization & Reprocessing), streamlined the process, and came up with a fast, potent method.
I watched Beverly Donovan apply the technique with her vets and interviewed her extensively about it, so I could describe it in my last book. I should also mention that Krakow's methods, in turn, are an outgrowth of Stephen LaBerge's groundbreaking work with Lucid Dreaming.
Used at the Brecksville V.A. with several hundred veterans suffering from the twin challenges of chemical dependency and posttraumatic stress, Nightmare Reprocessing was involved in outcome research and described in the Journal of Traumatic Stress,
And, according to Donovan, the success with the nightmares produces a kind of halo effect, creating such a sense of efficacy and well-being, that other PTS symptoms subside as well.
But little did I know it could help even a veteran of World War II with delayed onset PTSD (we're talking delayed here, people - as in 60 years!). Here's the story as best as I can recall.
An 84-year-old friend called me out of the blue, very distraught. Jimmy was in poor health from multiple, life-threatening illnesses, had had heart surgery, and this had somehow activated a repeating nightmare from an experience he'd had in France during World War II. (How heart surgery can catalyze latent flashbacks and nightmares, I haven't a clue, but it happens a fair amount.) Fear of the nightmare had made him afraid to fall asleep, and he was entering his third exhausted week.
I told him I knew of something that worked, but that I'd never actually used it on anyone myself. I had him read the pages in my book that described the technique (pp. 308-311) and asked him to think overnight about whether or not he wanted to try it, and, if he was game, we could give it our best shot the next day.
He was game. I came back. We started at step one, which was to have him tell me about the nightmare. Only he couldn't say it out loud (not uncommon -- too much shame and guilt), but he offered to write it out (Jimmy's own ingenious solution, and a good one).
I came back the next day and asked him if now he could tell me the nightmare. He said he couldn't, but he could read it to me (also a common reaction, and another intuitively inspired solution that gave him the emotional distance to proceed).
In the dream, he's leading a small cohort of men, crawling up an embankment amidst much shelling and mayhem -- lots of schrapnel, blood, body parts, deafening noise and terror. He becomes separated from his men. On his belly, he comes upon a machine gun nest with a dazed and, he guesses, half-blinded young German soldier in it -- a teenager, really -- who was fecklessly firing random rounds.
He tosses a grenade into the nest. It goes off. But when the dust settles, the kid is still upright somehow, looking even more dazed, probably deafened by the blast, but still firing away. Jimmy crawls around behind him and pulls his O.S.S.-issued stiletto out of his boot, hoists it up over his head, screaming blood-lust epithets at the top of his lungs, and targeting the back of the soldier's tender neck. This is when he wakes up.
This is a classic posttraumatic stress nightmare. It's not a regular dream, but a re-experiencing of something that actually happened, which got stuck in his brain.
Step 2: I ask him to tell me the negative assumption that the dream says about him. [Dr. Donovan had already given me a heads up that there are usually only three that the vets will tell you: (1) I'm a coward; (2) I'm a killer; or (3) I should have done more to help him/her.
He says he can't tell me. So I ask, "How about 'I'm a killer'?" He agrees that that's it.
Step 3: Then I ask him, "OK, so what's the positive assumption that this dream says about you?" He can't think of anything positive. (Dr. D. had also warned me this usually happens -- they can't think of anything good to say.)
I suggest, "Well, you say he was firing at American soldiers, right? How about 'I saved some lives today'?"
A scrupulously honest man, ever unwilling to make a false claim, Jimmy replies, "I can't say that. Maybe I saved some lives. Maybe I didn't. There's no way to know if I saved lives that day."
I offer, "OK, how about 'I may have saved some lives today'?"
Jimmy ponders a moment and acknowledges, "Based on the syntax of that sentence, I have to agree with you. I may have saved some lives that day."
Okay, so now we have the nightmare, we have the negative assumption that the nightmare connotes, and we have a countervailing positive assumption. So far, so good.
For Step four, I ask him what ending he can tack onto the dream that will allow him to wake up in a peaceful state. (I wonder what he'll come up with, being as how most of the Vietnam vets at Brecksville had angels and Jesus and magical reunions and reassuring conversations with dead comrades. But my friend Jimmy is a hardnosed agnostic, not so big on the Afterlife or angels. I have no clue what he'll do with this.)
To my surprise, he has no trouble with this coda: he imagines when the battle is over that a few of his men find him, and as they survey the damage and walk past the fox hole with the dead soldier, one of them points and says, "Boy, Oh boy, he really could have gotten us."
So here is Jimmy's assignment: for three weeks, once in the morning and once before bedtime, he is to get himself into a relaxed, receptive state by listening to five to 10 minutes of immersive guided imagery. (Only he doesn't have any use for my guided imagery, so he substitutes several minutes of his favorite classical music). Then he is to replay the dream in his mind, only tacking on the new ending. Then he is to repeat the positive assumption to himself, "I may have saved some lives today." Then he closes by listening to 10 more minutes of his classical music. That's it. The whole thing doesn't take more than 20 minutes.
The next day his wife called to report he'd slept that night like a baby. He woke up happy, calm and relieved. He was never to have the nightmare again.
He was calm and relieved even when some oncology test results came back saying that his treatment wasn't working, and there were no other options. He died a peaceful man a few months later. Really, it wasn't the cancer that was killing him so much as the nightmare.
Please send this story to anyone you know being hammered by combat nightmares. Jimmy would be pleased.
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