Hypnotic imagery rehearsal in the treatment of nightmares: A case report

American Journal of Clinical Hypnosis, Oct 2006 by Donatone, Brooke

Abstract

This case report discusses a patient who experienced frequent nightmares and chronic low-level anxiety during his 3 ½ year imprisonment. He developed post traumatic stress disorder (PTSD), in part because he adamantly insisted that he had been wrongfully incarcerated. The literature supports the use of hypnotic imagery rehearsal for treating nightmares that stem from PTSD. Due to the patient's distrust of others and trauma history, it was uncertain whether hypnotic intervention would be effective. It is of note, there is no indication in the literature that hypnosis has been used with people on parole, let alone individuals who believe they were wrongly accused of committing a crime.

Keywords: Nightmares, hypnotic imagery rehearsal, wrongful incarceration, post traumatic stress disorder

Trauma symptoms impact individuals in a variety of ways, often manifesting as nightmares. There is growing evidence to support the use of imagery rehearsal therapy as one of the most effective treatments for nightmares. (Germain, Krakow, Faucher, Zadra, Nielsen, Hollifield, et al., 2004; Krakow, Sandoval, Schrader, Keuhne, McBride, Yau, et al., 2001; Krakow, 2006).

Incarceration is an example of a traumatic event that often has a profound effect on prisoners. Case studies have documented nightmares in incarcerated adults and juveniles who committed crimes, but no research has documented wrongly accused adults and their related nightmares (Halliday, 2004). This paper explores the use of hypnotic imagery rehearsal while the patient experienced nightmares both during incarceration and when he was on parole. It is important to consider treatment with this population since 6.9 million Americans were reported to be incarcerated, on probation or parole, a 275% increase since 1980 (Bureau of Justice Statistics, 2005).

A traumatic event is not restricted to a person's past in the same way that other life events may be cataloged and filed in the brain. Instead, they intrude upon visual, auditory, and/or other somatic realities (Rothschild, 2000). Traumatized people frequently lose signal anxiety, thus are unable to modulate their level of arousal. Reactions to benign stimuli are similar to reactions to threatening stimuli, and the person becomes frozen in a hyperaroused state (Bloom, 1997). Lacking a verbal narrative these traumatic sensations and images become encoded and released as flashbacks and nightmares (Herman, 1992). Interventions such as hypnotic imagery rehearsal may be useful to change these images into something safer and less intrusive. Hypnosis research and practice supports the use of a wide range of clinical applications. Yet there has been limited investigation into its application for diverse populations.

Case History

"Max" is a 23-year-old Caucasian male. He was referred to me by his "wife's therapist," - his wife suggested that he try hypnosis to manage his chronic anxiety. Max worked in the construction industry and had limited employment opportunities as a result of his felony charge and conviction.

This is a brief summary of his life history: At age 12 his parents divorced and he was left with his alcoholic mother, who was frequently passed out, or screaming, or neglectful. As a result, outside the home, he was often left alone on the streets of his unsafe neighborhood. Max's life became one of survival and instinct instead of reason and insight. His temper led him to many physical fights, which became his primary mode of communication and expression. He was an imposing figure at a tattooed, muscular 6'3'' build.

Max was imprisoned for 3 ½ years for the armed robbery of a gas station, but insisted upon his innocence. Max's version of the incidents preceding his arrest was that the police had shown him surveillance camera footage of a man robbing the store who did not resemble him; that after his arrest the police severely assaulted him and knocked out several of his front teeth; and that a confession was coerced out of him after he was physically assaulted and forced to stand handcuffed for over 8 hours without food, water, or a bathroom break.

Since his release one year before, he had nightmares about being chased by police or returning to jail at least once a week. Additionally, his wife would awaken him during the night because he would moan or thrash in his sleep, though he did not remember these nightmares. He had tremendous difficulty being alone, at which time he experienced high levels of anxiety. At all other times, he experienced a persistent low-level anxiety, which he denied having prior to imprisonment. He frequently obsessed about minor stressors including his job, finances, and his marriage. Additionally, he reported a chronic depressed or apathetic mood and little excited him. These symptoms appeared to have been present prior to incarceration.

The patient denied any use of recreational drugs or alcohol, according to the rules of his parole. He had no prior treatment. According to the DSM-IV, Max met the criteria for post traumatic stress disorder with comorbidity of dysthymia and generalized anxiety disorder (American Psychiatric Association). Max agreed to come for weekly sessions until the symptoms abated.