Exposure, Relaxation and Rescripting Therapy

1. Introduction

Version followed: Joanne L. Davis's ERRT as published in Treating Post-Trauma Nightmares: A Cognitive Behavioral Approach (Springer, 2008/2009; three-session manual), with the current University of Tulsa format (weekly 90-minute sessions over 4–5 weeks) and the adaptations ERRT-M (military and veterans), ERRT-B (bipolar disorder) and ERRT-C (children) noted where they differ. The book's session scripts and the current manual (released only through ERRT training) are not reproduced here, and the trial papers are drawn on through their published abstracts; the manual's step-level wording is therefore [uncertain]. Checked against: session format and components against the developer's TRAPT lab page and ERRT empirical-research page; session allocation against the Center for Deployment Psychology (CDP) description; the dismantling and active-duty trials against their published abstracts; ERRT-C and ERRT-B design against a trial record and the developer's research listing. Still [uncertain]: the manual's fine detail; how many times the nightmare is written or read aloud in session; whether accounts are read aloud in group formats; what ERRT-M's mindfulness elements are; the session content of ERRT-C and ERRT-B. No single-session or 'brief' B-ERRT protocol is published [uncertain]: in the developer's listings the B variant is the bipolar adaptation.

Exposure, Relaxation, and Rescripting Therapy (ERRT) is a brief cognitive behavioural treatment for chronic trauma-related nightmares and the sleep problems that go with them. Davis developed it at the University of Tulsa, starting in 2001, where her TRAPT lab (Trauma Research Assessment Prevention & Treatment) continues to study it [source: University of Tulsa news 2020; TRAPT lab page]. The first published case, an adolescent rape survivor, appeared in 2003 (Davis, De Arellano, Falsetti & Resnick). Davis and Wright (2006) described the approach as building on imagery rehearsal by adding an enhanced exposure component, trauma themes and sleep-habit change [source: ERRT empirical-research page (abstracts)]. It draws on both sleep medicine and psychology. Davis's stated rationale is that post-trauma sleep problems often run partly separately from PTSD and can persist after other PTSD symptoms resolve, so they are targeted directly [source: University of Tulsa news 2020; Springer book page]. The model treats nightmares as kept going by three kinds of factor: physiological (arousal), behavioural (poor sleep habits and avoidance) and cognitive (trauma-related themes in the dream content). The treatment hits each one in turn: relaxation and sleep-habit change for arousal and behaviour, written and spoken exposure to the nightmare to reduce fear and avoidance, and rescripting of the nightmare around a trauma theme (power, trust, intimacy, esteem, safety). The new script is then rehearsed every night before sleep [source: TRAPT lab page; Lefkowitz, CDP; ERRT programme site]. Davis originally thought exposure was the key mechanism. A dismantling trial (Pruiksma et al., 2018; 70 adults) compared full ERRT with a version without nightmare exposure and rescripting. Both shared psychoeducation, sleep-habit change and relaxation, both improved nightmares, sleep, PTSD and depression, and they did not differ at any point up to 6 months. The authors suggest that the exposure dose may have been too low, or that the shared components are enough for some people, so the active mechanism is still unsettled [source: Pruiksma et al. 2018 abstract; Lefkowitz, CDP].

2. Framework

Format and dose [source: ERRT programme site; Lefkowitz, CDP; Springer TOC; UTulsa trial page]

Published manual (2008): 3 sessions, given individually or in groups. One clinician summary describes them as about 60 minutes each [source: CDP staff perspective, node 3061]. The programme site gives 60–120 minutes depending on individual or group delivery.
Current Tulsa protocol: 1.5-hour sessions once a week for 4–5 consecutive weeks, individual or group [source: TRAPT lab page]. The ERRT site states 4–5 sessions; the CDP gives 3–5 sessions of 90–120 minutes and notes that length varies between studies [source: ERRT site; Lefkowitz, CDP].
ERRT-M (military and veterans): sessions lengthened from 60 to 90 minutes, a fourth session added (Balliett et al., 2015; 19 veterans) and mindfulness built in. The source says only that ERRT-M was modified to 'incorporate the use of mindfulness interventions' [source: CDP node 3061; ERRT empirical-research page]. The active-duty pilot RCT (Pruiksma et al., 2020; 40 service members; Fort Hood) used five sessions against a 5-week minimal-contact control, with 17.5% dropout, and participants rated the treatment credible [source: Pruiksma et al. 2020 abstract; PubMed 31957648; UTulsa news]. The TRAPT lab reports that the Department of Defense marked ERRT for rollout through Army medical education in summer 2015 [source: TRAPT lab page].
Other adaptations. ERRT-B (also written B-ERRT; bipolar disorder): a modified five-week version piloted with 7 trauma-exposed adults with bipolar disorder, 6 of whom reported no nightmares at 3-month follow-up (Miller, Davis & Rhudy, 2018, Dreaming) [source: ERRT empirical-research page]. ERRT-C (children and adolescents aged 5–17): 5 sessions over 5 weeks, with a parent or guardian taking part in home assignments. The University of Tulsa trial (NCT01776229; randomised against a waitlist, with crossover) excluded apparent psychosis, pervasive developmental disorder, intellectual disability and verbal comprehension below a Peabody Picture Vocabulary Test cut-off [source: ERRT-C trial record, Veeva mirror]. An earlier case series adapted ERRT for children (Fernandez et al., 2013) [source: ERRT empirical-research page]. Related formats from the same literature: a three-session inpatient case series (Reiter & Humphreys, 2021); a six-session veteran group combining imagery rescripting and exposure (IRET; Long et al., 2011); a 10-session group combining CBT-I with exposure, rescripting and relaxation (Swanson et al., 2009) [source: ERRT empirical-research page]. The session-level content of ERRT-B and ERRT-C is not published in the public sources [uncertain].
Group delivery is used. One published case describes six weekly group sessions with combat veterans [source: Psychiatric Times].

Phase structure (three-session manual; the five-session version spreads the same content)

Phase	Goals	Content	Move on when
Pre-treatment assessment	Confirm trauma-related nightmares; separate them from other sleep events; set a baseline	Trauma assessment, nightmare and sleep assessment (book ch. 2), Trauma-Related Nightmare Survey, sleep and nightmare log	Nightmares are linked to a trauma; no exclusion is present; other sleep pathology has been ruled out or referred
Session 1: education and arousal reduction	Give a shared model of how nightmares are maintained; start reducing arousal and unhelpful sleep habits	Psychoeducation (trauma, PTSD, nightmares, sleep), sleep-habit review and change (sleep hygiene, stimulus control), progressive muscle relaxation (PMR)	The client understands the rationale, has a sleep-habit change plan and has started daily relaxation practice
Session 2: exposure and rescripting	Process the target nightmare and build a new version	Write the nightmare and read it aloud with distress ratings, identify themes, rescript, add diaphragmatic breathing, set up nightly rehearsal	A rescript exists that the client finds credible and less distressing; the nightly rehearsal routine is agreed
Session 3: consolidation	Review progress and prevent relapse	Review logs and skill use, troubleshoot rehearsal, refine the rescript if needed, plan for relapse prevention	Treatment ends; further nightmares are handled with the same skills

[source: Springer TOC (chapters 'Session 1–3'); CDP node 3061.] The CDP page puts psychoeducation and PMR first and review, maintenance and relapse prevention last. The exposure, theme, rescripting and diaphragmatic-breathing content sits between them, but the page does not number that session, so placing it in session 2 is inferred [uncertain]. The criteria for moving on are [synthesis]: the public sources give no formal progression rules.

Selection and exclusion used in the developer's trials: acute or apparent psychosis; unmedicated bipolar disorder (B-ERRT is a separate adaptation); intellectual disability or severe cognitive impairment; active suicidality or recent parasuicidal behaviour; untreated substance use disorder in the past 6 months (or current dependence); past or current mania in ERRT-M. Inclusion: DSM-5 trauma exposure and about one nightmare a week for the past month [source: NCT02236377 record via decentrialz mirror; CDP node 3061 on Balliett et al. 2015]. These are research criteria. Treat them as clinical cautions rather than absolute bars [synthesis].

Monitoring: weekly nightmare frequency, nights with nightmares, severity and distress, fear of sleep, insomnia, PTSD and depression were the trial outcomes [source: PubMed 31957648]. The developer's group publishes the Trauma-Related Nightmare Survey (TRNS; 16 items, Cranston et al., 2016) for clinical and research use [source: UTulsa trial page]. Trial response was defined as zero nightmares a week at follow-up [source: CDP on Balliett et al. 2015].

3. Guiding principles

Target nightmares and sleep directly, not only as PTSD symptoms. Do not assume nightmares will resolve with trauma-focused PTSD treatment. Assess and treat sleep in its own right [source: UTulsa news 2020].
Work on three maintaining pathways (physiological, behavioural, cognitive). Each session adds a tool for each: relaxation, sleep-habit change, then exposure and theme-based rescripting [source: CDP node 3061].
Interdisciplinary stance: sleep medicine plus psychology. Screen for and refer other sleep disorders, and do not treat every disturbed night as a nightmare [source: Springer description; book ch. 2 title].
Start with the worst. ERRT targets the most frequent and most intense nightmare first. It does not climb a hierarchy as some IRT formats do [source: Psychiatric Times].
Face the nightmare, don't avoid it. Writing it out and reading it aloud is deliberate exposure. This distinguishes ERRT from IRT, where the details are not written or spoken [source: Lefkowitz, CDP].
Rescript to the theme, not just to something pleasant. Keep the basic storyline and change it so that it addresses the trauma theme the client has identified (safety, trust, power/control, esteem, intimacy) [source: Psychiatric Times; CDP].
The client authors the rescript. The therapist helps find the theme. The client chooses the changes, so the new script feels credible [source: Psychiatric Times case; the emphasis on client choice is [synthesis]].
Daily practice carries the treatment. Relaxation is practised daily and the rescript is rehearsed every night before bed. Most change is expected to happen between sessions [source: CDP node 3061; Psychiatric Times].
Brief and structured. Three to five sessions, each with set content. Keep to the agenda and use the treatment-considerations guidance for problems rather than extending the work open-endedly [source: Springer TOC; ERRT site].
Measure from start to finish. Track nightmares, sleep and distress ratings before and after exposure and rescripting [source: Psychiatric Times (SUD ratings); PubMed 31957648 outcomes].

4. Intervention inventory

The components below are the ones named in the public descriptions [source: ERRT programme site; Lefkowitz, CDP; CDP node 3061; Psychiatric Times]. The step-by-step detail comes from those descriptions where they give it. Where they don't, it is marked [synthesis] (standard CBT-for-sleep and exposure practice, not attributed to Davis). The manual's own handouts and participant-manual wording are not reproduced here [uncertain]. All example language is illustrative.

4.1 Pre-treatment assessment of trauma, nightmares and sleep

Purpose / when: Before session 1. Confirm the trauma exposure and the trauma-related nightmares, pick the target nightmare, separate nightmares from other sleep events, and set a baseline [source: Springer TOC, ch. 2 "Assessment of Trauma, Nightmares, and Sleep Problems"; Springer description: "differentiating sleep events"].
Steps:
1. Assess trauma history and current PTSD and depression symptoms with your usual validated measures. Trials used structured PTSD interviews such as the CAPS [source: CDP node 3061].
2. Map the nightmares. For each: how often, how intense, how closely it replays the trauma versus thematically related content, and what happens on waking. The TRNS (Cranston et al., 2016) is the developer group's instrument; use it under its own terms and do not copy items [source: UTulsa trial page].
3. Screen for other sleep problems: insomnia, possible sleep apnoea, and violent or complex movements during sleep. Refer for sleep-medicine evaluation or polysomnography when these suggest another sleep disorder [source: Psychiatric Times (violent movements and polysomnography); specific apnoea screening is [synthesis]].
4. Check the trial cautions: psychosis, unstable bipolar disorder or mania, active suicidality or recent self-harm, untreated substance use disorder, significant cognitive impairment [source: NCT02236377 mirror; CDP node 3061].
5. Start a daily sleep and nightmare log (bedtime, sleep onset, wakings, nightmares, distress) to run through treatment [source: trial outcome set, PubMed 31957648; log format is [synthesis]].
Example language (illustrative): "Over the last month, how many nights a week have you woken from a bad dream? Is it the same dream, or different dreams about similar things?"
Watch for: sleep events that are not nightmares (night terrors, possible REM sleep behaviour disorder, apnoea arousals); nightmares with no trauma link (ERRT's theme work assumes one) [synthesis]; current suicidal ideation, which needs a risk assessment and safety plan before you start [synthesis].

4.2 Psychoeducation: trauma, PTSD, nightmares and sleep

Purpose / when: Session 1. Gives a model that explains why nightmares persist and why each component is there, and builds credibility and expectancy [source: ERRT programme site; CDP node 3061; PubMed 31957648 (credibility and expectancy measured)].
Steps:
1. Describe common trauma reactions and PTSD in plain terms, and normalise them.
2. Explain that nightmares are common after trauma, can become a self-sustaining problem, and may persist after other symptoms improve [source: UTulsa news 2020].
3. Give the three-pathway model: body arousal, sleep habits and avoidance, and the meaning (themes) in the dream. Link each to a component of treatment [source: CDP node 3061].
4. Describe basic sleep regulation and how nightmares disrupt it (fear of sleep, delaying bedtime, stimulants or alcohol) [source: trial outcomes include fear of sleep; detail is [synthesis]].
5. Preview the sessions: relaxation and sleep changes now, then writing and changing the nightmare, then nightly practice.
Example language (illustrative): "Nightmares can turn into a habit the brain keeps running, especially when you're on edge at night and dreading sleep. We'll work on three things: calming your body, changing sleep habits that keep the problem going, and changing the dream itself."
Watch for: the client's belief that nightmares are fixed or meaningful omens; shame about avoidance of sleep; rate how credible the rationale feels [synthesis].

4.3 Modification of sleep habits (sleep hygiene)

Purpose / when: Session 1 onward. Removes behaviours that keep arousal and poor sleep going [source: ERRT programme site ("modification of sleep habits"); CDP node 3061].
Steps:
1. Review the log and interview for maladaptive habits: irregular sleep and wake times, caffeine, nicotine or alcohol near bed, screens or trauma-related media before bed, napping, sleeping with lights or TV on, checking or hypervigilance routines [synthesis: specific habit list].
2. Agree 1–3 concrete changes, prioritising a regular set bedtime and wake time. A set bedtime anchors the rehearsal routine [source: Psychiatric Times: rehearsal “about 1 hour before a set bedtime”].
3. Write the plan down and log adherence.
Example language (illustrative): "Which one change this week would make the biggest difference: a fixed wake-up time, cutting the late coffee, or turning the news off an hour before bed?"
Watch for: safety behaviours that also serve real safety needs (for example, a client living with ongoing threat). Adapt rather than remove [synthesis].

4.4 Stimulus control

Purpose / when: Session 1, alongside sleep habits, when the bed has become linked with wakefulness or dread. The CDP lists stimulus control in ERRT and notes its overlap with CBT-I [source: Lefkowitz, CDP].
Steps (standard CBT-I procedure; ERRT-specific wording [uncertain]): use the bed only for sleep and sex; go to bed only when sleepy; if awake for roughly a quarter of an hour, or after a nightmare and unable to settle, get up and do something calm in dim light, returning when sleepy; keep a fixed rising time; avoid daytime naps [synthesis/uncertain on ERRT's exact rules].
Example language (illustrative): "If you wake from the dream and can't settle, get up, go to another room, use your relaxation for a bit and only go back when you feel sleepy."
Watch for: temporary extra sleepiness; avoid applying strict sleep restriction without CBT-I competence (it is not named as part of ERRT in the public descriptions) [synthesis].

4.5 Progressive muscle relaxation (PMR)

Purpose / when: Taught in session 1 to reduce physiological arousal. It is the ERRT relaxation method (IRT tends to use breathing) and is paired with the nightly rehearsal [source: Psychiatric Times; CDP node 3061].
Steps:
1. Give the rationale: tension and arousal keep the body ready for threat at night.
2. Guide the client through tensing and releasing muscle groups in sequence (for example hands and forearms, upper arms, face, neck and shoulders, chest and back, abdomen, legs and feet), with a brief tension and a longer release, noticing the contrast [synthesis: standard PMR; the manual's muscle-group sequence and script are [uncertain]].
3. Rate tension or relaxation before and after (0–100).
4. Homework: practise relaxation at least twice daily, and do PMR after the nightly rescript rehearsal [source: CDP node 3061].
Example language (illustrative): "Make a fist with your right hand, notice the tightness… hold… and now let it go. Notice how the hand feels as it softens."
Watch for: relaxation-induced anxiety or intrusions as the body slows down. Keep eyes open and shorten the practice if needed [synthesis]. Avoid tensing injured areas.

4.6 Diaphragmatic breathing

Purpose / when: Taught after the exposure and rescripting work (session 2 in the three-session manual) as a second, portable arousal-reduction skill [source: CDP node 3061].
Steps:
1. One hand on the chest, one on the abdomen. Breathe in slowly through the nose so the abdomen rises more than the chest.
2. Exhale slowly, slightly longer than the inhale, at an unforced pace [synthesis: technique detail].
3. Homework: about 10 minutes, as part of the at-least-twice-daily relaxation practice [source: CDP node 3061].
Example language (illustrative): "Let the breath drop down into your belly… and a slow, easy breath out."
Watch for: over-breathing or dizziness. Slow down and normalise [synthesis].

4.7 Written exposure to the target nightmare

Purpose / when: Session 2 (three-session manual), after relaxation skills are in place. Reduces fear and avoidance of the nightmare content. The target is the client's most frequent and most intense nightmare [source: Psychiatric Times; Lefkowitz, CDP; CDP node 3061].
Readiness and consent [synthesis unless tagged]: The client understands the rationale and agrees to it. Relaxation has been practised at least a few times. No current crisis, active suicidality, acute psychosis or intoxication (trial exclusions) [source: NCT02236377 mirror]. The client knows they can pause. Agree a grounding plan in advance.
Steps:
1. Take a distress rating (SUD, 0–100) before writing [source: Psychiatric Times].
2. The client writes a detailed account of the nightmare as it is usually dreamed, in the present tense if acceptable, including sensory detail, thoughts and feelings in the dream [source: Psychiatric Times (“detailed account”); tense and sensory prompts are [synthesis]].
3. Take a distress rating after writing [source: Psychiatric Times].
4. Dose: one written account of the one target nightmare in session, followed by reading it aloud (4.8). The public descriptions give no repetition count or habituation threshold, and the CDP descriptions do not say whether the account is read once or repeatedly [uncertain]. The dismantling-trial authors suggest that ERRT's exposure dose may have been too low to add benefit beyond the other components [source: Pruiksma et al. 2018 abstract].
Example language (illustrative): "Write the dream the way it usually goes, from the start to the moment you wake, with as much detail as you can: what you see, hear, feel. Before you start, how distressed are you from 0 to 100?"
Watch for: skipping the worst moment (gently ask what happens there); dissociation (glazed look, slowed responses, numbness), in which case pause and ground (see section 5); distress that stays high and does not come down by session end. Note that nightmare content is the client's dream experience, not a record of events to check or interpret as recovered memory.

4.8 Verbal exposure: reading the nightmare aloud

Purpose / when: Straight after writing, in session. Speaking the content deepens contact with the feared material. This written-plus-spoken exposure is what distinguishes ERRT from IRT [source: Lefkowitz, CDP; ERRT site (“written and verbal exposure”)].
Steps:
1. The client reads the written account aloud to the therapist.
2. Rate distress. Ask briefly what was hardest and what they noticed [synthesis].
3. Use the account to identify themes (4.9).
Example language (illustrative): "Now I'd like you to read it out loud to me, at your own pace. I'll be right here. We'll check in when you're done."
Watch for: speeding up or monotone reading as avoidance; long silences; shame about content (for example, perpetrator or moral-injury elements). Validate and continue [synthesis].

4.9 Identifying trauma themes in the nightmare

Purpose / when: Session 2, after exposure. Links the nightmare to how the trauma affected beliefs about the self, others and the world. The theme then guides the rescript [source: Psychiatric Times; Lefkowitz, CDP].
The five ERRT themes: safety, trust, power/control, esteem (self-esteem), intimacy [source: Psychiatric Times; Lefkowitz, CDP; ERRT site]. These mirror the trauma-affected belief areas familiar from cognitive trauma therapy [synthesis: the link is an observation, not stated in the ERRT sources].
Steps:
1. Briefly explain the five areas and how trauma can disrupt each.
2. Ask the client which themes run through the nightmare, and which is strongest. Help by pointing to specific moments in the account.
3. Agree on the predominant theme (one or two) [source: Psychiatric Times (“predominant theme”; the case named safety and control)].
Example language (illustrative): "Looking at the dream, where do you feel least safe? Where do you have no control? Which of these feels most like the heart of it?"
Watch for: a client who names a theme to please you. Check it fits by asking how they would feel in the dream if that theme were resolved [synthesis].

4.10 Rescripting the nightmare

Purpose / when: Session 2, directly after theme identification. Builds a changed dream that addresses the identified theme. It is not a free rewrite: ERRT keeps the basic content and adds or changes elements that address the theme [source: Psychiatric Times; Lefkowitz, CDP contrasting IRT's free rewrite].
Steps:
1. Keep the opening and the general setting of the nightmare [source: Psychiatric Times (“basic content is kept”)].
2. The client decides at what point and how the dream changes so that the theme is resolved: for example, gaining power or control, being safe, being able to trust someone appropriately, valuing themselves, being close to someone [source: themes from Psychiatric Times/CDP; example changes are [synthesis]].
3. The client writes out the rescripted version in full.
4. Rate distress for the rescripted dream [source: Psychiatric Times].
5. Optionally the client reads the rescript aloud and you refine together any parts that feel implausible or that slip back into the original [synthesis].
Example language (illustrative): "Keep the beginning the same. Then, at the point where you used to feel trapped, what would need to change for you to feel safe, or back in control? It's your dream: you decide what happens."
Watch for: rescripts that rely on revenge or graphic violence (may keep arousal high), or on implausible magic the client does not believe in. Steer toward the theme and toward credibility rather than intensity [synthesis]. A rescript with a distress rating clearly below the original's is a sign it is working [inferred from SUD use, Psychiatric Times].

4.11 Focused rescripting of the most difficult segment

Purpose / when: After the first rescript, if one part of the nightmare remains most distressing [source: Psychiatric Times].
Steps: Isolate that segment, repeat theme identification for it, then rescript only that segment and fold it back into the full rescript [source: Psychiatric Times]. Rate distress again [synthesis].
Example language (illustrative): "The part with the door still feels the worst. What's going on for you in just that moment, safety, control or something else? How could that moment go differently?"
Watch for: endless revising as a form of avoidance; agree a version to rehearse this week [synthesis].

4.12 Nightly rehearsal of the rescripted dream, followed by PMR

Purpose / when: Homework from session 2 onward, every night. Builds the new script into the pre-sleep routine [source: ERRT site; CDP node 3061; Psychiatric Times].
Steps:
1. At a set time about 1 hour before bedtime [source: Psychiatric Times], read and then imagine the rescripted dream vividly, for about 15 minutes [source: CDP node 3061].
2. Follow the imagery with PMR [source: CDP node 3061; Psychiatric Times].
3. Go to bed at the set time. Log nightmares, distress and sleep.
4. If the client struggles, they can contact the therapist between sessions [source: Psychiatric Times].
Example language (illustrative): "Each night, about an hour before bed, read your new version, then close your eyes and run through it like a film for about 15 minutes. Then do your muscle relaxation and head to bed at your usual time."
Watch for: rehearsing the original nightmare by mistake (only the rescript is rehearsed) [synthesis]; rehearsal skipped because it feels distressing (troubleshoot in session); early signs of working: lower distress on rehearsal, nightmares less frequent or less intense, or the dream changing in the rescripted direction, and less fear of going to sleep [source: trial outcomes, PubMed 31957648; dream-change marker is [synthesis]].

4.13 Progress review, maintenance and relapse prevention

Purpose / when: Final session (session 3 in the manual) [source: CDP node 3061; Springer TOC].
Steps:
1. Review logs from baseline to now: nightmare frequency, intensity, sleep, use of skills.
2. Review how the rescript, relaxation and sleep-habit changes are being used. Refine the rescript if needed.
3. Plan for relapse: possible triggers (anniversaries, new stressors, reminders); early signs; what to do (restart nightly rehearsal, write and rescript any new or returning nightmare using the same steps, recheck sleep habits) [source: relapse prevention named by CDP node 3061; content is [synthesis]].
4. Discuss remaining PTSD or other symptoms and refer for trauma-focused PTSD treatment if indicated (in trials PTSD did not always change) [source: CDP node 3061 (no CAPS change in Balliett et al.); referral is [synthesis]].
Example language (illustrative): "If a nightmare comes back, what will you do first?"
Watch for: attributing gains to luck. Point out the skills the client used [synthesis].

4.14 Mindfulness elements (ERRT-M)

Purpose / when: Added in the military/veteran adaptation. The CDP summary of Balliett et al. (2015) says only that ERRT-M was modified to 'incorporate the use of mindfulness interventions' [source: CDP node 3061]. The active-duty RCT abstract does not mention them [source: Pruiksma et al. 2020 abstract].
Steps: Not described in the public ERRT sources [uncertain]. Do not reconstruct a protocol. If you use a mindfulness exercise, use a standard brief one (for example, a few minutes of breath-focused awareness), presented as [synthesis].
Watch for: n/a beyond standard mindfulness cautions for trauma survivors (offer eyes-open options and choice).

4.15 Delivery formats and adaptations

Group: ERRT is delivered individually or in groups [source: TRAPT lab page; ERRT site], and group sessions are longer [source: ERRT site]. A published veteran case used 6 weekly group sessions with 4 other members [source: Psychiatric Times]. Long et al. (2011) ran a six-session group (IRET) for veterans with PTSD [source: ERRT empirical-research page]. The public sources do not say whether, in groups, accounts are written individually and read aloud to the group or only to a therapist [uncertain]. Agree confidentiality and content rules first [synthesis].
ERRT-C (children 5–17) and ERRT-B (also written B-ERRT; bipolar disorder): see section 2 for what was verified. ERRT-C: 5 weekly sessions, ages 5–17, and a caregiver joins home assignments. ERRT-B: a five-week pilot in bipolar disorder [source: ERRT-C trial record; ERRT empirical-research page]. A CDP podcast with Shantel Fernandez-Lopez, one of the developers of CBT for nightmares in children, confirms that ERRT has been modified for children and adolescents. The adaptations themselves are described only in the audio [source: CDP podcast ep. 56]. Session-level protocols are not published [uncertain]. Do not improvise them without training. For children, involve carers and adapt language and writing demands [synthesis].
Training: the current manual is only provided through ERRT training. The developer lists approved providers and trainings [source: UTulsa trial page].

5. Handling problems

Davis's book has a chapter, "Treatment Considerations", which the publisher says gives suggestions for difficulties therapists or clients may meet [source: Springer description and TOC]. That chapter's content is not reproduced here, so almost all of what follows is [synthesis] unless tagged otherwise.

Overwhelm or dissociation during writing or reading aloud [synthesis]: Stop the exposure, not the session. Ground the client: feet on the floor, describe five things in the room, say today's date and where they are, hold a cold object, take slow breaths with eyes open. Then return to the account in smaller pieces (for example, write up to the hardest moment, ground, then continue), or read aloud with eyes open and pauses. Before the client leaves, do a relaxation exercise and check that distress has come down to a manageable level and they are oriented. If dissociation is frequent or severe, postpone exposure and do stabilisation and grounding-skills work first, or consider a non-exposure route: the dismantling trial suggests the relaxation, education and sleep-habit components alone also helped [source for the dismantling result: Lefkowitz, CDP].
Distress or nightmare rebound after session 2 [synthesis]: Forewarn clients that some temporary increase is possible. Ask them to keep up nightly rehearsal and PMR and to log it, and offer between-session contact [source for contact: Psychiatric Times]. Review at the next session and refine the rescript.
Avoidance of homework (skipped rehearsal or relaxation) [synthesis]: Find out the specific barrier (forgetting, distress, no privacy, shift work). Tie practice to a fixed cue an hour before the set bedtime. Shorten rehearsal at first. Problem-solve with the log. Revisit the rationale: daily practice is where change happens.
Rescript doesn't take: the original dream keeps returning unchanged [synthesis]: Check that the client is rehearsing the rescript and not the original, that the rescript addresses the theme they named, and that it is believable. Use focused rescripting of the hardest segment [source for the segment step: Psychiatric Times]. Check whether a different theme (for example trust rather than safety) is the real driver.
Several different nightmares [synthesis/uncertain]: ERRT starts with the most frequent and most intense one [source: Psychiatric Times]. Gains may generalise. If another nightmare persists, apply the same write, read, identify-theme and rescript steps in a later session. How the manual handles multiple nightmares is [uncertain].
Nightmares that replay the trauma exactly (replicative nightmares) [synthesis]: Exposure to these is close to trauma-memory exposure. Confirm consent and readiness, keep closure steps, and consider whether full trauma-focused PTSD therapy is indicated in parallel or afterwards. Rescripting changes the dream, not the memory: tell clients so, and do not use rescripting to rewrite or explore what "really" happened.
Content involving the client's own actions (combat, moral injury) [synthesis]: Esteem and power themes are common. Validate, and avoid rescripts that whitewash. Consider adjunct moral-injury or guilt-focused work.
Ongoing danger (current abuse, unsafe housing, deployment) [synthesis]: Safety-focused rescripts may clash with reality. Address real safety first, and treat some vigilance habits as reasonable.
Possible other sleep disorder (thrashing, acting out dreams, loud snoring or gasping, unrefreshing sleep despite fewer nightmares): Refer to sleep medicine or for polysomnography [source: Psychiatric Times for violent movements; others [synthesis]]. The developer's group has studied how suspected sleep apnoea affects ERRT outcomes (Miller et al., 2018) [source: ERRT empirical-research page]. Persistent insomnia after nightmares improve may need full CBT-I [synthesis].
Suicidality or self-harm [synthesis, in line with standard practice]: Trials excluded active suicidality and recent parasuicidal behaviour [source: NCT02236377 mirror]. Cogan et al. (2019) examined ERRT's effect on suicidal ideation [source: ERRT empirical-research page]. Assess risk at intake and when nightmares or distress flare. Use a collaborative safety plan, including lethal-means counselling (safe storage and removal), and pause exposure work during an acute crisis.
Substance use as a sleep aid [synthesis]: Untreated substance use disorder was a trial exclusion [source: NCT02236377 mirror]. Assess. Alcohol worsens sleep architecture and nightmares on withdrawal. Coordinate with addiction care and do not start exposure while the client is intoxicated.
Bipolar disorder or psychosis [source for exclusion: NCT02236377 mirror; CDP node 3061; ERRT-C trial record]: Standard ERRT trials, and the ERRT-C trial, excluded these. For bipolar disorder the developer's group piloted a modified five-week ERRT-B (Miller, Davis & Rhudy, 2018) [source: ERRT empirical-research page]. Use it only with that protocol and training, and protect regular sleep [synthesis].
Medication for nightmares [synthesis]: Some clients take medication prescribed for nightmares. Coordinate with the prescriber and do not advise changes. ERRT can be delivered alongside medical care.
Low cognitive flexibility or literacy [synthesis]: Theme-based rescripting is described as demanding abstract thinking and cognitive flexibility [source: Psychiatric Times]. Offer the themes as a short menu with concrete examples. Allow dictation instead of writing. Consider a simpler free-rescript approach (IRT) if theme work is not workable.
Rupture: client feels pushed into exposure, or that the therapist chose "their" theme [synthesis]: Name it, apologise for pace, give back choice (what to write, when to pause, what the rescript says) and restate the rationale. Exposure only proceeds with consent.
Group-specific problems [synthesis]: One member's graphic account can trigger others. Set content rules, consider having accounts read to a therapist privately, and keep a co-facilitator available for grounding.
Partial response at the end of a brief course [synthesis]: Add one or two booster sessions using the same steps. The five-session versions show the dose can be extended [source: UTulsa trial page; PubMed 31957648]. Then reassess for PTSD treatment, CBT-I or sleep-medicine referral. The developer's group has studied predictors of non-starting, dropout and response (Miller et al., 2019). It has also proposed ERRT for nightmares that remain after PTSD treatment (McDermott et al., 2021) [source: ERRT empirical-research page].

Sources

Web pages:

Books and papers cited:

Davis, J. L. (2008/2009). Treating Post-Trauma Nightmares: A Cognitive Behavioral Approach. New York: Springer.
Davis, J. L., & Wright, D. C. (2007). Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. Journal of Traumatic Stress, 20(2), 123–133.
Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological Trauma, 10(1), 67–75.
Balliett, N. E., Davis, J. L., & Miller, K. E. (2015). Efficacy of a brief treatment for nightmares and sleep disturbances for veterans. Psychological Trauma. doi:10.1037/tra0000055
Pruiksma, K. E., et al. (2020). A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel. Journal of Clinical Sleep Medicine, 16(1), 29–40. doi:10.5664/jcsm.8116
Cranston, C. C., et al. (2016). Trauma-Related Nightmare Survey. doi:10.1080/15299732.2016.1191578
Davis, J. L., De Arellano, M., Falsetti, S. A., & Resnick, H. S. (2003). Treatment of nightmares related to post-traumatic stress disorder in an adolescent rape victim. Clinical Case Studies, 2(4), 283–294.
Davis, J. L., & Wright, D. C. (2006). Exposure, relaxation, and rescripting treatment for trauma-related nightmares. Journal of Trauma & Dissociation, 7(1), 5–18.
Fernandez, S., DeMarni Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A case series: Cognitive-behavioral treatment (exposure, relaxation, and rescripting therapy) of trauma-related nightmares experienced by children. Clinical Case Studies, 12(1), 39–59.
Miller, K. E., Davis, J. L., & Rhudy, J. L. (2018). Pilot study: Brief posttrauma nightmare treatment for persons with bipolar disorder. Dreaming, 28(2), 150–161.
Miller, K. E., Cranston, C. C., Simonet, D. V., Pruiksma, K. E., & Davis, J. L. (2018). The impact of suspected sleep apnea on Exposure, Relaxation, and Rescripting Therapy (ERRT): A preliminary examination. Journal of Sleep Disorders and Medical Care, 1(1).
Miller, K. E., Micol, R. L., Davis, J. L., Cranston, C. C., & Pruiksma, K. E. (2019). Predictors of treatment non-initiation, dropout, and response for cognitive behavioral therapy for trauma nightmares. Psychological Trauma, 11, 122–126.
Cogan, C. M., et al. (2019). The impact of Exposure, Relaxation, and Rescripting Therapy for post-trauma nightmares on suicidal ideation. Journal of Clinical Psychology, 75(12), 2095–2105.
McDermott, T. J., et al. (2021). Exposure, Relaxation, and Rescripting Therapy could treat residual nightmares following PTSD treatment. Psychiatry Research, 295, 113630.
Reiter, S. R., & Humphreys, J. (2021). Exposure, Relaxation, and Rescripting Therapy for trauma-related nightmares with psychiatric inpatients: A case series. Clinical Case Studies, 20(1), 3–21.
Long, M. E., et al. (2011). Imagery rescripting and exposure group treatment of posttraumatic nightmares in veterans with PTSD. Journal of Anxiety Disorders, 25(4), 531–535.
Swanson, L. M., Favorite, T. K., Horin, E., & Arnedt, J. T. (2009). A combined group treatment for nightmares and insomnia in combat veterans: A pilot study. Journal of Traumatic Stress, 22(6), 639–642.

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