Imagery rehearsal therapy

Domain VI · Brief, integrative, trauma, hypnosis & coaching · Barry Krakow

What it is

IRT is a brief cognitive-imagery treatment that targets nightmares directly, whether they follow trauma or occur on their own. You do not have to treat the underlying trauma first. In Krakow's model, nightmares may begin as a way of processing a stressful event but can persist as a learned,…

Format

• Versions and formats
• Across the studies in Casement & Swanson's 2012 meta-analysis, IR protocols ran 3–10 sessions (most IRT protocols 3–6) of about 60–200 minutes (most 60–120), mostly in groups.

Who practises it, and how they are trained or regulated

• Imagery skills training. Goal: the patient can form vivid, multisensory, pleasant or neutral images and can step out of unwanted images. Move on when they can hold a neutral scene and use the stop-and-breathe or shift skill. Krakow notes some patients need extended practice.

Evidence status, as the guide reports it

• Across the studies in Casement & Swanson's 2012 meta-analysis, IR protocols ran 3–10 sessions (most IRT protocols 3–6) of about 60–200 minutes (most 60–120), mostly in groups.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• Pressure (from you or the patient) to start with the worst nightmare before skills are in place.
• Group members comparing trauma details. Keep the focus on the method, not the trauma narratives.
• Being able to complete the new dream without the nightmare taking over. Calm or positive affect afterwards.
• Overloading with too many scripts. Some nightmares changing on their own once the first one has shifted (ask about this).
• Whether nightmare frequency falls even with non-nightmare content. Krakow frames IRT as new learning, so this is expected to help.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.