Counseling after Disaster

Henry Fuslini: Nightmare

Follow Up Counseling After Disaster: Working With Traumatic Dreams Toward Healing

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Penny Dahlen, Ed.D., NCC, LPC
University of Wyoming
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ABSTRACT
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This article discusses posttraumatic nightmares as a symptom of PostTraumatic Stress Disorder. The differences between ordinary nightmares and posttraumatic nightmares are described. A Traumatic Dream Defusing Process is presented for working with posttraumatic dreams in counseling following a traumatic event. Techniques for assisting survivors to process their traumatic dreams outside of the counseling session are addressed.
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Follow Up Counseling After Disaster: Working With Traumatic Dreams Toward Healing
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INTRODUCTION
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In 1900 Sigmund Freud published The Interpretation of Dreams which brought the mystery of dreaming into scientific investigation. He considered dreams to reveal unconscious material and placed importance on deciphering the meaning of the dream. Jung (1964) rejected Freud's theory and approached dreams from working with symbols and mythology and worked with series of dreams in order to understand his patients' psychological difficulties. In their work with dreams, neither Freud nor Jung recognized trauma as a primary source of a nightmare. It wasn't until the 1960's when Vietnam War Veterans began having nightmares about war events that traumatic dreams were given much investigation (Barrett, 1996). By the 1980 publication of the Diagnostic and Statistical Manual (Third Edition), Post Traumatic Stress Disorder (PTSD) acknowledged and labeled traumatic stress and included nightmares as one of the symptoms.
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The purpose of this article is to provide an innovative method for working with traumatic dreams that counselors can use when working with survivors of disaster. The approach presented in this article has been used with survivors of childhood incest and automobile accident survivors and it seems logical that it can be applied to survivors of disaster. Survivors of childhood incest, automobile accidents and disasters have all been shown to exhibit symptoms of PostTraumatic Stress Disorder (Van der Kolk, McFarlane & Weisaeth, 1996).

PTSD AND TRAUMATIC DREAMS
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PostTraumatic Stress Disorder (PTSD) occurs after a person has experienced a traumatic event such as natural disaster, participating in combat, or being a victim of physical assault or rape. People who suffer PTSD often re-experience the event through intrusive thoughts, dreams, acting or feeling as if the event were reoccurring and/or intense distress (APA, 1994). They tend to avoid stimuli associated with the event and have inability to recall aspects of the disaster. Thus, they develop hyper-arousal and tend to experience sleep problems because they deliberately wake themselves up in order to avoid having traumatic nightmares (van der Kolk, McFarlane & Weisaeth, 1996). When they do sleep they often experience the exact replica of the traumatic event in a dream. These nightmares and recurring dreams are common symptoms of PTSD.
A distinction between ordinary nightmares and traumatic nightmares is necessary for understanding and working with the material in dreams. Barrett (1996) reported that ordinary nightmares and traumatic nightmares differ in content and in repetitiveness. Many people have nightmares that haven't experienced trauma. These nightmares can be called ordinary nightmares. Ordinary nightmares have been studied by Hartmann (1984) who describes the content as variable and could include dreamer being chased, threatened, or wounded by some form of chaser or attacker. There is almost always danger of some kind and the content is described as vivid with many different forms, thus not exactly repetitive.
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Posttraumatic nightmares are repetitive and possess more memory intrusion of the traumatic event than ordinary nightmares (Barrett, 1996). Their content is the exact replay of an actual scene from the disaster or traumatic event. The same post traumatic nightmare sequence involving the replay of the event can occur not only during various stages of sleep but during waking; thus called a flashback rather than a nightmare. The repetitive PTSD nightmare is a memory, in contrast to ordinary nightmares, that can intrude suddenly into the consciousness as if the event is happening all over again.
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The PTSD nightmare can be experienced the first night following the disaster. For example, the night after students survived the Columbine High School shootings in Littleton, Colorado; many survivors had nightmares of the incident from that day. They continue to experience PTSD nightmares for days and months following the tragedy and may again have nightmares on the anniversary of the incident years later.
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TDDP: A MODEL FOR WORKING WITH TRAUMATIC DREAMS
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One of the most common models for working with groups after a disaster is the Critical Incident Debriefing Model developed by Mitchell and Everly (1993). Their model is a seven stage process to debrief groups after a disaster and is designed to mitigate the traumatic impact on the psychology of the survivors, as well as prevent the development of Post Traumatic Stress Disorder symptomology. Some of the ideas of the Critical Incident Debriefing Model have been borrowed to develop the Traumatic Dream Defusing Process (TDDP) for working with posttraumatic dreams. However, the Critical Incident Debriefing Model is not to be used or substituted as psychotherapy and TDDP is a process to be used in a psychotherapeutic relationship. For purposes of this Process, defusing is defined as decreasing the intrusive impact of the traumatic memory in the dream. Applying TDDP in working with individuals and their traumatic dreams has potential to increase healing from symptoms of PTSD. The Process approach would help defuse the traumatic dream and empower the survivor to continue to work with dreams outside of the counseling session. The Traumatic Dream Defusing Process is delineated in the following phases throughout one counseling session:
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Phase 1 - Introduction: It is important to ask the survivor how their sleep life has been to assess if he/she has been experiencing post traumatic dreams. It can also be helpful to discuss that working with the dreams can help defuse some of the memory from the trauma and get a contract that the survivor/client is willing to work with his/her dreams. Finding out about the client's sleeping environment is important too. The survivor needs to feel safe at night so when he/she wakes from the traumatic dream there is something comforting and grounding around. Suggest pillows or some comforting object to sleep with. Losing a significant other that one slept with every night can be devastating. An example of how to introduce dream work and continue through all phases of the Traumatic Dream
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Defusing Process follows:
Counselor: "How has your sleep been since the avalanche?"
Linda: "Not very good. I keep having the same terrifying dream over and over and I wake up sweating and crying."
Counselor: "That sounds very hard. I wonder if you would be willing to work with the dream in here today?"
Linda: "What good will that do?"
Counselor: "Sometimes by working with the dream and telling the story through the dream, the dream may be less intrusive in your sleep."
Linda: "O.K. anything that will help. I am so tired of all of this."
Counselor: "How about starting with telling me about your comfort level in your bed at home?"
Linda: "I really miss Tim. I wake up and just want him to hold me but he's not there." Counselor: "What makes you feel safe?"
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Phase 2 - Fact: Ask the client about the specific facts of the dream. This is the dream content. Have the client start from the beginning of the dream and describe the content. The counselor might say "and then what happened?" to facilitate fact gathering. Stating the details of the dream out loud is important in order to understand all parts of the traumatic dream. Providing voice to all the details of the dream helps the client tell his/her story and thus helps defuse the power of the traumatic dream.
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Counselor: "So tell specifically what happens in your dream from the beginning every detail you can remember."
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Linda: "Well, I am on my skis on Tim is in front of me with our dog George. He tells me to stay back as he skis over to the edge. Then the ground rumbles and he and George get swept away in this huge wall of snow. I start screaming for them and then I start sliding on the side of the avalanche. I can't hold onto anything. The snow is heavy and pulling me down the mountain. Big chunks of snow are flying by me. This goes on for a very long time. I luckily don't get buried but can't see Tim or George anywhere. I start digging frantically through the snow for them but can't find them and then I wake up screaming and sweating.

Counselor: "The dream sounds very similar to what really happened that day."
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Phase 3 - Thought: During the thought processing phase, the counselor wants to pose questions about the clients cognition's during the dream, such as "What thoughts were going through your mind when you were in the dream?" During this phase, the counselor wants to try to help the client work with survivor guilt for having made it through a disaster when others died.
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Counselor: "What were you thinking in the dream?"
Linda: "My first thought was to Tim and wondering why I couldn't stay right behind him. And then I thought they jumped off the edge and were teasing me but once the ground rumbled, I knew it was bad. I kept thinking I should grab on to something and that I should save them."
Counselor: "It sounds like you did all you could do. What were you thinking in the dream when you were digging for them?" Linda: "I have to find them. I can't give up."
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Phase 4 - Reaction: The reaction processing of the session is for processing emotions about the dream/event. The emotions experienced in a traumatic dream can be the worst part. Experiencing intense fear during the reliving of the event in a dream is traumatic all over again. The counselor might say "What feelings were you experiencing during the dream?" It is important to help the client identify the feelings and for the counselor to reflect and validate those feelings. By having the client talk about and express his/her emotions in an accepting environment, the client can learn to accept and express these feelings when waking from a traumatic dream at home.
Counselor: "What feelings were you experiencing in your dream?"
Linda: "I was terrified, absolutely helpless and terrified." Counselor: "It sounds so awful and scary. Tell me more about the fear and helplessness."
Linda: "I couldn't do anything." (starts to cry)
Counselor: "This is such a big loss and so sad."
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Phase 5 - Symptom/Sensory: The symptom processing is to help the client get in touch with sensations or body memories they may be experiencing during the dream. Questions could include: "What were you feeling in your body?" or "What other sensations did you experience during the dream?" The purpose of Phase 5 is to help the client get in touch with how the traumatic experience is experienced in their body in the nightmare so that they can understand and defuse these sensations by providing a voice to the body sensations.
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Counselor: "What other sensations do you feel in your body during the dream?"
Linda: "I just start shaking all over and my heart pounds and I actually feel the big hunks of snow fly by me like heavy wind."
Phase 6 - Re-Play: It can be helpful to have the client replay the dream through a position of strength and rewrite it. Techniques for replay include drawing the dream, including the facts, thoughts, feelings, and sensations. Then have the client draw the dream how they could change it to feel safer in the dream. This technique helps the client have some sense of control over what happens in his/her dream life. It is also helpful to work with the client's spirituality in dream work. This includes asking about their faith and how they can include prayers, meditations, or guidance into their healing with their dreams.
Counselor: "That is a very powerful dream and memory. Would you be willing to draw it?"
Linda: "I guess." (As Linda draws the dream, tears of fear and sadness run down her cheeks and the counselor reflects her pain.)
Counselor: "Linda, if you could have someone or something in the dream with you to make it feel safer, who or what would it be?"
Linda: "I guess I would want Tim and George alive but I know that isn't going to happen. So maybe if I have an angel it would help."
Counselor: "How does your spirituality help you and how can you incorporate that in your dream?"
Linda: "I believe in angels and that Tim and George are with the Angels now."
Counselor: "Why don't you draw the angels into the picture and see if that helps some?" (Linda draws the angels into the picture and continues to cry and grieve over her loss. Toward the end of the session, the counselor suggests Linda start keeping a dream journal so she can see how the traumatic dream starts to change and lose power. She also encourages Linda to continue to ask for help from the angels as she goes to sleep at night.)
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Phase 7 - Teaching: The teaching part of the model is to educate the client that the traumatic dreams are normal ways to continue to work through the memory of the trauma. Educating the client about how to continue to work with their dreams outside of session is crucial. Suggesting a dream diary where the client writes down the content, thoughts, feelings, and sensations of the dream can be beneficial in tracking posttraumatic nightmares and the progress in healing. Encouraging them to tell their dreams to other friends and family members can be helpful too. The more the traumatic dream story is told, in writing, drawing, and verbally, the quicker the defusing will take place.
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CONCLUSION
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This article discussed the difference between ordinary nightmares and post traumatic stress nightmares. Posttraumatic nightmares are a memory intrusion of the traumatic event and differ from an ordinary nightmare in content and repetitiveness. The Traumatic Dream Defusing Process has the potential to assist survivors of disaster in healing some of the symptoms of PTSD by working with posttraumatic nightmares. To date, little research has been conducted on the effects using the TDDP model. The author has used the model in working with survivors of childhood incest and automobile accidents. Since these clients experienced some relief in from their symptoms of PTSD by working through the posttraumatic nightmare and survivors of disaster also experience nightmares as symptoms, it seems logical to extend the TDDP model to working with survivors of disasters.
REFERENCESAmerican Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (Third Ed.).
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American Psychiatric Association: Washington D.C. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Ed.). American Psychiatric Association: Washington D.C.
Barrett, D. (1996). Trauma and dreams. Cambridge, Massachusetts: Harvard University Press.
Freud, S. (1900) 1965. The interpretation of dreams. New York: Avon.
Hartmann, E. (1984). The nightmare: the psychology and biology of terrifying dreams. New York: Basic Books.
Jung, C. (1964). Man and his symbols. New York: Laurel.
Mitchell, J. T., & Everly, G.S. (1993). Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers. Baltimore, Maryland: Chevron Publishing.
van der Kolk, B. A., McFarlane, A.C., & Weisaeth, L. (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: The Guilford Press.
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Penny Dahlen is an Assistant Professor of Counselor Education at the University of Wyoming. Comments regarding this article can be sent to pldahlen@uwyo.edu or by mail % College of Education, University of Wyoming, Laramie, WY 8207