Imagery Rehearsal Therapy
Imagery Rehearsal Therapy is a brief cognitive-behavioral treatment for nightmares developed by Barry Krakow in 1995. It treats the nightmare as a learned behavior rather than a symptom to wait out: the client rewrites the dream while awake and rehearses the new version in imagery, which reduces nightmare frequency and distress, probably through memory reconsolidation and reduced conditioned fear. Guidance on it is split by scope: the AASM's 2018 position paper recommends it for nightmare disorder and PTSD-associated nightmares, while the 2023 VA/DoD and 2025 APA PTSD guidelines find insufficient evidence for or against it as a PTSD treatment. Krakow's 2001 JAMA trial is its best-known randomized study. It takes three or four sessions individually or in a group, and it matters because nightmares routinely survive an otherwise successful course of PTSD treatment.
Related condition topics
These links support exploration. They do not establish that Imagery Rehearsal Therapy is effective or recommended for each condition.
How Imagery Rehearsal Therapy works
Cognitive rescripting of nightmare content combined with imagery rehearsal changes nightmare frequency and distress through mechanisms likely involving memory reconsolidation and reduced conditioned fear
Ontology
Nightmares as a learned maladaptive sleep behavior that can be directly targeted and modified through intentional cognitive and imaginal intervention
Therapeutic Voice
"Pick any part of the nightmare and change it however you want. It doesn't have to make sense, and it doesn't have to be the ending. Then we'll rehearse the new version until it's the one that comes easily."
View of the Person
A person whose nightmare disorder reflects a learned pattern of conditioned fear response that can be modified through intentional cognitive and imaginal intervention
Epistemology
Evidence
1 condition assessment available
An overall effectiveness assessment has not been completed. Completed assessments for specific populations appear below.
Condition-specific assessments
Each conclusion applies to the population and use described. These source-based assessments do not certify the full entry or replace expert clinical review.
PTSD & Acute Trauma
Population and scope: Adults with PTSD-associated nightmares.
Guideline evidence inconclusive
VA/DoD 2023 recommendation 33 is inconclusive. AASM’s 2018 position paper recommends IRT for nightmares; it is not a graded CPG or a recommendation for all PTSD symptoms.
Source assessment dated
Guidelines and official sources (3)
2 clinical guideline checks · 1 professional reference check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Clinical Practice Guideline for Management of PTSD and Acute Stress Disorder
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against IRT for nightmares associated with PTSD.
Scope: Nightmares associated with PTSD
- Position paper for the treatment of nightmare disorder in adults
Recommendation for the stated population
AASM recommends IRT for these nightmare presentations. It calls this a position paper, not a graded CPG.
Scope: Adults with nightmare disorder or PTSD-associated nightmares
- Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults
Insufficient evidence for or against
APA finds insufficient evidence for or against IRT for adult PTSD relative to no intervention or treatment as usual. This is a different scope from AASM’s nightmare-specific position.
Scope: IRT for adults with PTSD compared with no intervention or treatment as usual
Recorded material under review
The existing notes below are retained separately from assessment records. These recorded claims await source checking, including study design, recommendations and numerical estimates.
Multiple RCTs including landmark Krakow et al. (2001) JAMA study; replicated across PTSD and civilian nightmare populations
Cochrane review and meta-analyses support efficacy for nightmare frequency and distress
Under-used in clinical practice relative to how often nightmares persist after trauma treatment. Guideline positions differ by scope: the AASM recommends it for nightmares, while the 2023 VA/DoD and 2025 APA PTSD guidelines find the evidence insufficient either way for PTSD. Nightmares are a core PTSD symptom that standard PTSD treatments often do not fully resolve, which is the practical case for knowing IRT: a client can complete a full course of trauma treatment and still not sleep. Brief and structured enough to be completed in 3-4 sessions.
Training and certification
General CBT training plus IRT-specific workshop or self-study; relatively accessible
No formal certification; training available through workshops and published materials
1-2 day workshop sufficient for competent delivery
$200-800 for workshop training
Equity & Cultural Adaptations
Clinical cautions and blind spots
Assessment and precautions
Active psychosis, severe dissociation where imagery work risks destabilization, inability to generate or hold mental imagery, acute suicidality
Blind spots
Requires willingness to engage with nightmare content; some find rescripting counterintuitive; not suitable during acute destabilization; limited training infrastructure
Philosophical roots
Behavioral learning theory; cognitive appraisal; Lang's bio-informational theory of emotional imagery (emotional processing theory proper is Foa and Kozak's later extension of it); sleep science
Compared with other approaches
Test Yourself
Can you actually change what you dream by rehearsing a different version while awake?
Show answer
Yes. IRT is based on evidence that nightmares are a learned sleep disorder and that mentally rehearsing an altered version while awake changes dream content. The mechanism is not fully understood but outcomes are robust.