Staff Perspective: Examining Exposure, Relaxation, and Rescription Therapy (EERT) for Nightmares
Balliett, N. E., Davis, J. L., & Miller, K. E. (2015). Efficacy of a brief treatment for nightmares and sleep disturbances for veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000055
Reviewing efficacy of Exposure, Relaxation, and Rescription Therapy (ERRT) for Nightmares in Veterans
Balliett, Davis and Miller (2015) conducted a pilot study to examine the efficacy of a modified ERRT protocol (ERRT-M) for veterans experiencing nightmares. Their literature review outlined three main reasons for continued investigation on clinical interventions for nightmares in military personnel. First, the authors noted that research reveals high prevalence rates of sleep-related disturbances among service members and veterans, to include nightmares for those in particular that have post-traumatic stress disorder (PTSD). The authors also note that clinical outcomes for the treatment of nightmares have been mixed in terms of effectiveness for military populations compared to civilian populations. Finally, the authors note that results from meta-analytic studies reveal comparatively small effect sizes for nightmare treatments compared to clinical interventions for other mental health conditions. These findings from the literature suggest that nightmare treatments are not only relevant for military populations, but may warrant some modifications to improve their efficacy.
Overview of ERRT for Nightmares
Davis (2009) developed a cognitive behavioral approach to the treatment of nightmares based on relevant psychological theory and results from previous studies. ERRT targets physiological, behavioral, cognitive aspects related to the development and maintenance of nightmares through a three-session treatment protocol. Each session is approximately 60 minutes and starts by providing psychoeducation about trauma, nightmares, and sleep hygiene, as well as teaching progressive muscle relaxation. The main emphasis is to provide relevant background information, modify maladaptive sleep habits, and to help patients gain proficiency with relaxation skills, such as progressive muscle relaxation. Next, treatment focuses on exposure to the nightmare, identifying trauma themes, rescripting the nightmare to address noted trauma themes, and teaching another relaxation skill (i.e., diaphragmatic breathing). Patients are to practice relaxation skills at least twice daily using diaphragmatic breathing for 10 minutes, review the rescripted nightmare nightly using imagery for approximately 15 minutes and engage in progressive muscle relaxation afterwards before going to bed. In the last session, the focus is to review treatment progress and the use of skills learned in treatment with patients, discussing maintenance and relapse prevention strategies.
Overview of Balliett et al. (2015) Study
The authors conducted an uncontrolled study (i.e., no comparison group) examining the efficacy of a modified EERT treatment protocol using a convenient sample of 18 veterans. The treatment was modified to extend the time of sessions from 60 to 90 minutes, include one additional session (four sessions versus three), and incorporate the use of mindfulness interventions. Participants were excluded if they had severe cognitive impairment that would be deemed to interfere with treatment, those with psychotic spectrum disorders, past or current manic symptoms, and current substance dependence. Based on previous research, Balliett et al. (2015) hypothesized that the modified ERRT protocol (i.e., ERRT-M) would improve the frequency and severity of nightmares, post-traumatic stress, depression, seven dimensions of sleep quality (i.e., general quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, sleep medication, and daytime dysfunction related to sleep), fear of sleep, and insomnia one week post-treatment and maintain treatment gains two months after treatment was completed. The authors administered measures pre-treatment, one week post-treatment, and two months follow-up assessment after treatment was completed.
What Did the Authors Find?
The authors found that a significant improvement in the number of nightmares reported per week, the number of nights patients experienced nightmares in the past week, improvements in general sleep quality, sleep latency, sleep duration, sleep efficiency, and daytime dysfunction, insomnia and fear of sleep, and symptoms of depression at both the one week and two month post-treatment assessment. No changes were noted on PTSD symptoms as a result of ERRT-M as measured by the CAPS (total past week scores). Overall, Balliett et al. (2015) found that 50% of their sample responded to treatment, defined as having zero nightmares per week at the two month post-treatment assessment. For the non-responders, the authors noted that significant differences occurred in the expected direction between pre-treatment and the one week post-treatment session (i.e., improvements in nightmares per week, nights with nightmares in the past week, nightmare distress, depression, global sleep quality, fear of sleep, and insomnia severity). However, for the non-responders the authors did not find significant differences between the one week and two month post-treatment assessment measures.
Clinical Implications and Future Research
Balliett et al. (2015) found a 65% reduction and 50% cessation of past week nightmares two months post-treatment using ERRT-M for a sample of military Veterans. Additionally, treatment responders were also observed to have decreased scores on symptoms of depression and improvement in a variety of other sleep quality indices. However, the finding that no changes were observed in PTSD symptoms for both treatment responders and non-responders suggests that these conditions may need to be treated separately. The authors suggest that additional research focus on clinical outcomes in military populations by integrating the treatment of PTSD and nightmares. Furthermore, future research should examine dose response impact for exposure techniques utilized in ERRT given the percentage of treatment responders in the study. Overall, the results of Balliett et al. (2015) appear promising, but need more replication to include controlled research designs and comparison to other treatments to determine its usefulness to other treatments for nightmares.
Timothy Rogers, Ph.D. is a Deployment Behavioral Health Psychologist for the Center for Deployment Psychology (CDP) at Joint Base San Antonio-Lackland Texas.
Balliett, N. E., Davis, J. L., & Miller, K. E. (2015). Efficacy of a brief treatment for nightmares and sleep disturbances for veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000055
Reviewing efficacy of Exposure, Relaxation, and Rescription Therapy (ERRT) for Nightmares in Veterans
Balliett, Davis and Miller (2015) conducted a pilot study to examine the efficacy of a modified ERRT protocol (ERRT-M) for veterans experiencing nightmares. Their literature review outlined three main reasons for continued investigation on clinical interventions for nightmares in military personnel. First, the authors noted that research reveals high prevalence rates of sleep-related disturbances among service members and veterans, to include nightmares for those in particular that have post-traumatic stress disorder (PTSD). The authors also note that clinical outcomes for the treatment of nightmares have been mixed in terms of effectiveness for military populations compared to civilian populations. Finally, the authors note that results from meta-analytic studies reveal comparatively small effect sizes for nightmare treatments compared to clinical interventions for other mental health conditions. These findings from the literature suggest that nightmare treatments are not only relevant for military populations, but may warrant some modifications to improve their efficacy.
Overview of ERRT for Nightmares
Davis (2009) developed a cognitive behavioral approach to the treatment of nightmares based on relevant psychological theory and results from previous studies. ERRT targets physiological, behavioral, cognitive aspects related to the development and maintenance of nightmares through a three-session treatment protocol. Each session is approximately 60 minutes and starts by providing psychoeducation about trauma, nightmares, and sleep hygiene, as well as teaching progressive muscle relaxation. The main emphasis is to provide relevant background information, modify maladaptive sleep habits, and to help patients gain proficiency with relaxation skills, such as progressive muscle relaxation. Next, treatment focuses on exposure to the nightmare, identifying trauma themes, rescripting the nightmare to address noted trauma themes, and teaching another relaxation skill (i.e., diaphragmatic breathing). Patients are to practice relaxation skills at least twice daily using diaphragmatic breathing for 10 minutes, review the rescripted nightmare nightly using imagery for approximately 15 minutes and engage in progressive muscle relaxation afterwards before going to bed. In the last session, the focus is to review treatment progress and the use of skills learned in treatment with patients, discussing maintenance and relapse prevention strategies.
Overview of Balliett et al. (2015) Study
The authors conducted an uncontrolled study (i.e., no comparison group) examining the efficacy of a modified EERT treatment protocol using a convenient sample of 18 veterans. The treatment was modified to extend the time of sessions from 60 to 90 minutes, include one additional session (four sessions versus three), and incorporate the use of mindfulness interventions. Participants were excluded if they had severe cognitive impairment that would be deemed to interfere with treatment, those with psychotic spectrum disorders, past or current manic symptoms, and current substance dependence. Based on previous research, Balliett et al. (2015) hypothesized that the modified ERRT protocol (i.e., ERRT-M) would improve the frequency and severity of nightmares, post-traumatic stress, depression, seven dimensions of sleep quality (i.e., general quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, sleep medication, and daytime dysfunction related to sleep), fear of sleep, and insomnia one week post-treatment and maintain treatment gains two months after treatment was completed. The authors administered measures pre-treatment, one week post-treatment, and two months follow-up assessment after treatment was completed.
What Did the Authors Find?
The authors found that a significant improvement in the number of nightmares reported per week, the number of nights patients experienced nightmares in the past week, improvements in general sleep quality, sleep latency, sleep duration, sleep efficiency, and daytime dysfunction, insomnia and fear of sleep, and symptoms of depression at both the one week and two month post-treatment assessment. No changes were noted on PTSD symptoms as a result of ERRT-M as measured by the CAPS (total past week scores). Overall, Balliett et al. (2015) found that 50% of their sample responded to treatment, defined as having zero nightmares per week at the two month post-treatment assessment. For the non-responders, the authors noted that significant differences occurred in the expected direction between pre-treatment and the one week post-treatment session (i.e., improvements in nightmares per week, nights with nightmares in the past week, nightmare distress, depression, global sleep quality, fear of sleep, and insomnia severity). However, for the non-responders the authors did not find significant differences between the one week and two month post-treatment assessment measures.
Clinical Implications and Future Research
Balliett et al. (2015) found a 65% reduction and 50% cessation of past week nightmares two months post-treatment using ERRT-M for a sample of military Veterans. Additionally, treatment responders were also observed to have decreased scores on symptoms of depression and improvement in a variety of other sleep quality indices. However, the finding that no changes were observed in PTSD symptoms for both treatment responders and non-responders suggests that these conditions may need to be treated separately. The authors suggest that additional research focus on clinical outcomes in military populations by integrating the treatment of PTSD and nightmares. Furthermore, future research should examine dose response impact for exposure techniques utilized in ERRT given the percentage of treatment responders in the study. Overall, the results of Balliett et al. (2015) appear promising, but need more replication to include controlled research designs and comparison to other treatments to determine its usefulness to other treatments for nightmares.
Timothy Rogers, Ph.D. is a Deployment Behavioral Health Psychologist for the Center for Deployment Psychology (CDP) at Joint Base San Antonio-Lackland Texas.