Nightmares are far more than a nuisance of a bad night’s sleep. For millions of people exposed to trauma, they are a persistent, distressing symptom that can foreshadow serious psychiatric illness. Among United States veterans, an estimated one in six experiences trauma-related nightmares, and these disturbing dreams are associated with elevated risk of developing posttraumatic stress disorder (PTSD) as well as suicidal thoughts and behaviors. Yet despite this heavy burden, nightmares are seldom reported to healthcare providers and remain largely untreated. A new commentary published in the Journal of Clinical Sleep Medicine argues that the solution may lie not in building more specialty clinics, but in delivering a standardized nightmare therapy directly into primary care and emergency departments, where trauma survivors already find themselves.
The treatment at the center of this effort is Cognitive Behavioral Therapy for Nightmares, abbreviated CBT-N. It is a recently standardized protocol that consolidates the key components of previously existing nightmare therapies, including exposure to nightmare content, nightmare rescripting, and imagery rehearsal. Historically, the behavioral nightmare treatment literature has been mired in confusion, with inconsistent use of treatment components across manuals that carried the same name. The impetus for formalizing these components under the CBT-N umbrella was, in part, to reduce that confusion and make it easier for clinicians to deliver nightmare therapy with fidelity. Because the manual is so new, however, important questions remain about how to bring the treatment to the patients who need it most, such as veterans, and how the protocol is received by providers working in different clinical settings.
A study by Bolstad and colleagues, recently published in the same journal, has begun answering those questions by bringing CBT-N into the Primary Care Mental Health Integration clinic at the Veterans Health Administration. This setting is notable for at least two reasons. First, behavioral health providers in this setting are embedded within primary care clinics, which do not typically assess nightmares. That integration allows behavioral health providers to see a much larger scope of patients than providers in traditional mental health clinics, including patients who may be reluctant to seek psychotherapy. Implementing CBT-N in this environment therefore has the potential to expand access to nightmare treatment for veterans at scale, reaching people who would never walk through the doors of a specialty sleep or PTSD clinic.
Second, the primary care mental health model follows a brief format of care, with patients receiving an average of two to three behavioral health sessions lasting only twenty to thirty minutes each. This is a stark departure from traditional mental health clinics, which typically entail at least six sessions of fifty to sixty minutes. CBT-N, by contrast, involves six sessions of sixty to ninety minutes. Evaluating the implementation of CBT-N in the primary care setting is therefore ideal for revealing how the treatment should be adapted for such a fast-paced environment, and whether the full protocol can survive compression into shorter encounters.
The findings from the Bolstad study reveal a striking tension between perceived benefit and perceived feasibility. Clinicians in the primary care integration setting perceived greater benefits of CBT-N for veterans compared to clinicians in other Veterans Health Administration mental health settings, such as the PTSD Clinical Team. They detected greater change in how veterans related to their nightmares, for example feeling less afraid of them, and they also perceived greater improvement in veterans’ mental health more broadly, including trauma-related and depressive symptoms and quality of life. Despite these perceived benefits, primary care clinicians rated CBT-N as less appropriate and less feasible to deliver than their counterparts in other settings did, with fifty-seven percent of them citing time constraints as the barrier. In response, the researchers propose adapting CBT-N for primary care by using shorter, more frequent sessions.
An important caveat accompanies these results. It is possible that veterans in the primary care setting appeared to do better because they were less distressed than those seen in traditional mental health clinics. Perhaps primary care clinicians intervened early in the nightmare-disease course, reducing the risk of worsening mental health, whereas clinicians in specialty settings likely saw patients who had already reached clinically significant distress. This interpretation assumes that nightmares are sentinel symptoms, the early treatment of which produces downstream preventive effects. That assumption could not be tested in the Bolstad study itself, but it is precisely the proposition now being examined in new research with acutely traumatized patients.
Nightmares affect anywhere from forty-six to seventy-three percent of acute trauma patients and serve as a prodrome for both PTSD and suicidal ideation. A research team at Henry Ford Health in Detroit is piloting a randomized controlled trial of behavioral sleep interventions delivered in the immediate aftermath of trauma, with the goal of halting the progression to post-trauma pathology. The trial enrolls patients discharged from thirteen emergency departments across the health system within seventy-two hours of a traumatic event. Patients are randomized and triaged based on symptoms to cognitive behavioral therapy for insomnia, CBT-N, or a sleep education control condition with or without nightmare education. Thus far, thirty-four patients have been randomized, most commonly following physical assault, and the demand for nightmare treatment has been significant, with more than eighty-five percent of acute trauma patients expressing interest in nightmare therapy.
The delivery method may be as important as the treatment itself. The interventions are delivered via telehealth video to reduce barriers to care, and the early numbers are encouraging: seventy-six and a half percent of randomized patients initiated treatment, whereas roughly half of patients discharged from the emergency department typically attend an outpatient mental health visit. Moreover, every patient enrolled so far found it very easy to attend the video sessions after trauma, and more than seventy percent said it would have been difficult to attend sessions had they been in person. When asked about preferred formats for future services, the overwhelming majority preferred video over in-person sessions, and all patients preferred video sessions over a mobile app. Future analyses will evaluate the preventive effects of early CBT-N and insomnia therapy on subsequent PTSD relative to control.
Together, these efforts point toward a broader rethinking of where mental health care happens. Providers working across different settings are encouraged to bring CBT-N into their own practices, including sleep medicine clinics, and can offer treatment to patients experiencing what researchers call DARC nightmares: dreams that cause Awakenings, are at least partially Remembered, and cause Clinically significant impairment. Remaining questions include whether and how CBT-N should be adapted for active-duty military personnel, first responders, and inpatients hospitalized after traumatic injury who may be physically unable to write about their nightmares as the protocol requires. Each population presents its own logistical and clinical constraints, and each represents a group in which nightmares are common but treatment access is scarce.
The overarching lesson from this line of research is sobering but actionable: not all who need mental health care are in the waiting rooms of behavioral health clinics. Nightmares are under-reported, under-detected, and therefore under-treated, and the patients most likely to benefit from nightmare therapy are often sitting in primary care offices or recovering at home after an emergency department visit rather than seeking specialty psychotherapy. As providers and researchers, the commentary’s authors argue, the field ought to be thoughtful about meeting patients where they are, and about adapting evidence-based treatments to fit those contexts, wherever they may be. If early intervention after trauma can genuinely interrupt the cascade toward PTSD and suicidal thinking, bringing nightmare therapy out of the specialty clinic and into primary and acute care could transform prevention for trauma survivors on a population scale.
Subject of Research: Implementation of cognitive behavioral therapy for nightmares in primary and acute care settings for trauma-exposed patients
Article Title: Bringing cognitive behavioral therapy for nightmares to patients with trauma: increasing access and feasibility via primary and acute care
Article References: Reffi, A. N., Peltzer-Jones, J., Moore, D. A., Johnson, J. L., & Drake, C. L. (2026). Bringing cognitive behavioral therapy for nightmares to patients with trauma: increasing access and feasibility via primary and acute care. Journal of Clinical Sleep Medicine, 22(1), Article 107. https://doi.org/10.1007/s44470-026-00108-5
Image Credits: AI Generated
DOI: 10.1007/s44470-026-00108-5
Keywords: nightmares, cognitive behavioral therapy, CBT-N, PTSD, trauma, veterans, primary care, emergency department, telehealth, sleep medicine, suicidal ideation, mental health access
News Source: Ophelia Keating. (October 7, 2026). Nightmare Therapy Moves Into Primary Care and Emergency Rooms to Reach Trauma Survivors. Scienmag.
