This is part II of a two-part blog. For part I, see Sunday’s post: https://johnsommersflanagan.com/2021/05/23/strategies-for-dealing-with-insomnia-and-nightmares-part-i/

Asking About Trauma

You may have a form to screen clients for a trauma history. However, more often than not, you’ll need to ask directly about trauma, just like you need to ask directly about suicidality. In many cases, as discussed in Chapter 3, it may be beneficial to wait and ask about trauma until the second or third session, or until there’s a logical opportunity. Although insomnia and nightmares don’t always signal trauma, when they co-exist, they provide an avenue to ask about trauma.

Counselor: Miguel, I’d like to ask a personal question. Would that be okay?

Miguel: Okay.

Counselor: Almost always, when people have nightmares about guns and death, it means they’ve been through some bad, traumatic experiences. When you’ve been through something bad or terrible, nightmares get stuck in your head and get on a sort of repeating cycle. Is that true for you?

Miguel: Yeah. I went through some bad shit back in Denver.

Counselor: I’m guessing that bad shit is stuck in your brain and one ways it comes out is through nightmares.

Miguel: Yeah. Probably.

Even when clients know their trauma experiences are causing their nightmares, they can still be reluctant to talk about the details. Physical and emotional discomfort associated with trauma is something clients often want to avoid. To reassure clients, you can tell them about specific evidence-based approaches—approaches that don’t require detailed recounting of trauma or nightmare experiences. Two examples include eye movement desensitization reprocessing (EMDR; Shapiro, 2001) and imagery rehearsal therapy (Krakow & Zadra, 2010). 

Miguel: If I talk about the nightmares, they get more real. I have enough trouble keeping them out of my head now.

Counselor: That’s a good point. But right now your dreams are so bad that you’re barely sleeping. It’s worth trying to work through them. How about this? I’ve got a simple protocol for working with nightmares. You don’t even have to talk about the details of your nightmares. I think we should try it and watch to see if your dreams get better, worse, or stay the same? What do you think?

Miguel: I guess maybe my nightmares can’t get much worse.

Evidence-Based Trauma Treatments

In Miguel’s case, the first step was to get him to talk about his insomnia, nightmares, and trauma. Without details about his experiences, there was no chance to dig in and start treatment. The scenario with Miguel illustrates one method for getting clients to open up about trauma. Other clinical situations may be different. We’ve had Native American clients who were having dreams (or not having dreams, but wishing for them), and we needed to begin counseling by seeking better understanding of the role and meaning of dreams in their particular tribal culture.

 Counselors who work with clients who are suicidal should obtain training for treating insomnia, nightmares, and trauma. Depending on your clients’ age, symptoms, culture, the treatment setting, and your preference, several different evidence-based treatments may be effective for treating trauma. The following bulleted list includes treatments recommended by the American Psychological Association (2017) or the VA/DoD Clinical Practice Guideline Working Group (2017), or both (Watkins et al., 2018).

• Cognitive Processing Therapy (Resick et al., 2017).
• Eye-Movement Desensitization Reprocessing (Shapiro, 2001)
• Narrative Exposure Therapy (Schauer et al., 2011)
• Prolonged Exposure (Foa et al., 2007).
• Trauma-Focused Cognitive Behavioral Treatment (Cohen et al., 2012).

Although the preceding list includes the scientifically supported approaches to treating trauma, you may prefer other approaches, many of which are suitable for treating trauma (e.g., body-centered therapies, narrative exposure therapy for children [KID-NET], etc.).

Specific treatments for insomnia and nightmares are also essential for reducing arousal/agitation. Evidence-based treatments for insomnia and nightmares include:

• Cognitive-Behavioral Therapy for Insomnia (CBT-I; Cunningham & Shapiro, 2018).
• Imagery Rehearsal Therapy (IRT; Krakow & Zadra, 2010).

Targeting trauma symptoms in general, and physical symptoms in particular (e.g., arousal, insomnia, nightmares) can be crucial to your treatment plan. Addressing physical symptoms in your treatment instills hope and provides near-term symptom relief.

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