A
Covid-19 Resource Paper for Therapists:
ICU VIVID DREAMS AND HALLUCINATIONS
Key words: ICU, Intensive Care experience, Covid-19, Coronavirus, Vivid Dreams, Nightmares,
Hallucinations, ‘Delusional Memories’, Trauma.
My background:
I am an existential and Sensorimotor
Trained Trauma psychotherapist and for almost 20 years worked as therapist, supervisor and trainer in the NHS. In 2001 I began
studying patients’ experience of ICU and then set up a Psychological Aftercare Service for ICU Patients at Croydon University
Hospital, which was the first routine service of its kind in the UK. During the following fifteen years until my retirement
from the NHS, I saw many hundreds of patients who had been ventilated in ICU.
My particular area of interest and expertise is working with
ICU Vivid Dreams and Hallucinations (so-called ‘delusional memories’). I have spoken on that subject,
and on patients’ experience of ICU, at conferences nationally and internationally, as well as on training and consultancy
days. I have also published on this subject.
Abstract:
Post-ICU patients are at high risk of PTSD - a recent
review and meta-analysis put it at 1in 5 (Righy et al. 2019). Helping post-ITU patients make sense of their nightmares can
release them from the grip of the panic and terror they experienced, and may still experience. In my long professional experience
in the field, making conscious sense of ICU vivid dreams helps patients to process them and to integrate into their ICU narrative
those fight/flight and other survival responses which the dreams typically express. In my professional experience, this has
led to a lessening of both the risk and symptoms of PTSD. Supporting reference will be made to recent advances in trauma therapy.
Key points about ICU vivid dreams and hallucinations.
It is clear that dreams in ICU have a vividness that is unlike that
of any ordinary dream or nightmare. It is often the first thing that patients talk about to their relatives on regaining consciousness
- with tales of being spied at through the holes of the polysterene-tiled ceiling, a particular doctor or nurse trying to
kill them, sexual orgies and babies being born - for the dreams are so vivid that patients have great difficulty distinguishing
dream from reality. This, not surprisingly, is likely to be met with a mixture of laughter and anxious concern. When an ICU
patient’s vivid experience is received in this way, they often fear for their sanity - as do the relatives. And a doctor
or nurse’s explanation that these are just ‘delusional memories’ may add to their fears. Vivid dreams
and hallucinations in ICU are a common occurrence and one of the major causes of distress for patients who have been in ICU.
This particular distress can usually be easily alleviated, yet, if not attended to, it can develop into PTSD. I have
been contacted by people who had suffered from their recurring ICU nightmares for years.
Rationale
The rationale for my way of working,
experientially developed over a period of almost 20 years, is now supported by recent neuroscientifically-informed trauma
therapies:
ICU vivid
dreams and ICU flashbacks, like other events experienced as traumatic, have bypassed conscious, cognitive processing. They
are stored as sensory fragments and, when triggered, these sensory experiences are then relived in their usually terrifying
unprocessed form. (And when a dream experience is traumatic, as on ICU, going to bed can become a trigger.) When patients
can make sense of their vivid dreams, acknowledge and sense their fight for survival, this helps to process and integrate
these vivid dreams into a personal, embodied narrative of their ICU journey - a narrative of active survival.
ICU dreamwork differs from ordinary dream work.
It consists of five basic steps:
1. Normalisation, psychoeducation and reassurance
2. Acknowledgement of the patient’s
experience
3. Asking
five vital questions
4.
Highlighting the theme
5.
Validation and Integration
Theoretical Reflections
Unless the thought of talking about their dreams
is clearly taking your patients to the edge of their Window of Tolerance, meaning work comes before resourcing and other body-focused
trauma work (Ogden et al. 2006). I cannot remember ever having the need to resource a client prior to telling a dream, other
than by respectful and holding listening.
Before moving onto practical notes and examples,
I believe that the following two reflections of Heidegger’s offer an enlightening perspective on the ICU vivid dreams
and hallucinations experience:
‘In understanding hallucinations, one must not start with the
distinction
between
‘real’ and ‘unreal’, but rather with an inquiry into the character of the
relationship to the world in which the patient is
involved at any given time.’
(Heidegger in Boss 2001: 152)
‘The dreamworld cannot
be separated as an object domain unto itself, but rather it belongs in a certain way to the continuity of being-in-the-world.’
(Heidegger
in Boss 2001: 229)
Ten Main Themes
Heidegger’s remarks point the way to viewing
ICU dreams as:
1.
reflecting the ICU life and death situation which addresses the patient and
2. expressing the patient’s response to that situation, which
includes fighting to survive.
This may be why, although each ICU dream tells a different story, ICU vivid dreams and
hallucinations usually fall under ten main themes:
a) doctors and nurses are trying
to kill me/pushing drugs/selling body parts
b) trying to escape
c) being attacked/chased/kidnapped by frightening people, creatures
or aliens
d)
trying to overcome an obstacle
e) being in a coffin
f) being on a journey, in a train/boat/plane
g) finding myself in a safe haven
(another hospital, a church etc.); special inspiration
h) having superhuman / healing powers
i) sexual orgies
j) babies
being born on ICU/next door
Although ‘doctors and nurses are trying to kill me’ (or variations on it) and ‘trying
to escape’ are the most common themes, the above themes are not listed according to frequency. Rather, while the first
four depict threatening situations, culminating, it would seem, in death (‘being in a coffin’), the following
five move (on a journey) towards greater safety (inspiration, healing powers) and life (sex and babies).
Personal
history and the immediate environment may well intrude into ICU dreams, as they would in ordinary dreams: so, for instance,
the nationality or ethnicity of nurses might well affect where the dream is taking place; someone with a history of torture
and interrogation may be reminded of their experience by the constant 24/7 light in ICU; the coronavirus, lockdown and various
family events, births, anniversaries etc are also likely to find their way into the vivid dreams’ storyline. These will
colour the dreams but usually not their principal significance.
WORKING with ICU VIVID
DREAMS and HALLUCINATIONS
1. Normalisation, Psychoeducation and Reassurance
Telling the patient that such vivid dreams and hallucinations
are a normal occurrence (usually starting between 3 and 5th day on ICU and lasting for a few days after discharge from the
unti) is a form of basic psychoeducation that offers normalisation and reassurance.
Psychoeducation also includes explaining the value of
trying to make sense of the dreams; that if these dreams are still recurring it is a form of PTSD and needs attending to;
that ICU vivid dreams are usually connected to patients’ situation on ICU.
When an initial exploration of the dream with the patient fails to
elicit their understanding of the connection between the dream experience and their real situation in ITU, psycho-education
involves asking questions, such as: ‘Would it surprise you if I told you that the most common theme among ITU patients’
dreams is trying to escape? ‘Do you have any idea why that should be?’ It may require further dotting the ‘i’s
and crossing the ‘t’s.
2. Acknowledgement
Acknowledging the experience means listening to the
dream, respectfully, without laughing and without dismissing it. Or apologising if you do laugh - acknowledging that on some
level it is comical, but clearly it is also scary/painful/important/inspiring etc.
Acknowledging the patient’s dominant emotion (panic, terror,
determination, inspiration)
Showing
curiosity about exploring its significance with the patient.
3. Asking Five Vital Questions:
who else was involved?
what were they like?
what were they doing?
how were
you feeling ?
and crucially, what were
you trying to do?
4. Highlighting the theme: A few examples
‘Sean’, ‘Tony’
and ‘Mat’ gave me permission to use their vivid dreams to try to help others. Sean’s and Tony’s had
been a recurring dream in ICU, Mat’s occurred only once and he had the sense of this being a turning point in his recovery.
Sean
What
had started off as a vivid dream in ITU, carried on for Sean as hallucinations after
discharge to the ward.
L:
Do you feel you can tell me about your vivid dream and hallucinations?
Sean: ‘I was lying there and there were all these silly little figures
on the ceiling.’ (cringes)
L. ‘Do you remember how you felt as you lay there?’
Sean: ‘I was shit scared. They were coming at me’
L. ‘Those silly little
figures?’
Sean:
‘Yes.’
L.
‘And what did they look like, could you describe them?’
Sean: ‘They were like hooded grim reapers.’
L. Hooded grim reapers, no wonder
you were shit scared! And what were you trying to do?
Sean: I was trying to fight them off.’
Until he was helped
to articulate it differently, Sean had thought of his experience of ICU as being a wimp, lying there in bed, terrified of
‘silly little creatures’ on the ceiling, while doctors and nurses were tending to him and making him better. By
the end of our session, he came to realise that those creatures were far from ‘silly’, he was terrified of them
for a very good reason, and he himself had had a role to play in his own recovery as he sought to fight them off.
The
concept of the patient having an active role in their survival even in Intensive care is not to be dismissed: consultant not
infrequently tell patients that they have done all they can, and it is now up to them (the patient).
Tony
Tony had been reliving his nightmare
ever since his discharge from ITU a few
days previously, and was very distressed. Like many other patients, Tony couldn’t see why ICU
patients should dream of trying to escape (which I told him was the most common theme), nor could he understand how his ICU
dream could reflect his ICU situation. What most upset Tony was that ‘line’ while he was trying to go home.
L.
A line?
Tony:
A white line on the ground, and you mustn’t cross it. Cries. And I’ve tried to get
round it...
L. And what would have happened if you’d gone
over that line?
T.:
crying, I don’t know, if I went over it, it would mean my number’s up.
Tony replied as if
that was obvious and yet a moment earlier he could not understand what was so upsetting about that line! For until I had asked
him directly, his knowledge had not been explicit - he knew at some level that he had to avoid crossing that line, but had
not articulated the reason to himself.
Mat
Mat: I was underwater
L. Ah yes?
Mat: yeah, I was underwater and and I was in a lot of
pain, and then suddenly the pain got lesser, and I could feel I was rising, rising slowly
L: You had less pain and were slowly rising?
Mat: Yeah, and I knew that not
feeling pain wasn’t right. I must feel that pain, and
then I started going down again [underwater].
L: You thought you must feel that pain and mustn’t
come up to the surface? What do you think would have happened if you had gone on rising?
M.: silence. I think I would have died. silence.
That really felt like it was a
turning point for me.
Yet although Mat amazingly ‘knew’, in his
dream consciousness, that it was vitally important for him to feel his pain, it wasn’t until I asked him what he now
thought might have happened if he had come up to the surface, that he articulated for himself that he would have died. Articulating
this enabled Mat to marvel at what he had done.
Even in ‘coffin’ dreams, it is worth
asking for clarification: the person may be trying to get out, which, macabre though it may sound, is an amazing example of
fight for survival.
The fight for survival need not involve an obvious fight/flight
response, it can show itself as trying shout, to find a safe place ( a church, a plane transformed into a hi-tech
hospital inside etc.), or even to have the answers, when interrogated with ‘life and death’ questions. This is
worth stressing, as patients often view their vain attempts at shouting and escaping - vain, since they are intubated and
unable to get out of bed, as signs of their helplessness.
Moving towards life
The last five themes show a progressively
stronger movement away from death: journeys by various means of transport (boat, train, plane - that often look like care
centres inside), safe havens, healing powers, inspirational dreams...
Jem recalled Blondie at her bedside
singing ‘You can’t let this happen to a girl like you’, specially for her; it gave her, she said, a real
boost. And I could simply acknowledge how special that must have felt. No further clarification was necessary: the song’s
words said it all.
ICU and sex and baby
dreams
When
patients’ ICU vivid dreams are about sex, they may feel embrassed at describing them - especially to partners, even
if they are about nurses having sexual orgies and babies. And it may not be necessary to clarify details, because the sex
and baby dreams, though often distressing, are most clearly about survival: for clearly, there is no more powerful symbol
of a life force than sex and babies being born!
Patients are to be reminded that these dreams are not, in essence, about being oversexed, disloyal
or having ‘loose morals’, but about engaging with life.
5. Transformation and
integration of ICU vivid dreams:
Moving from Terror to Empowerment
Of course there will be some
dreams that do not fall under any of the above categories and of which it will be difficult to make any sense. In such cases
it can be helpful to simply acknowledge the patient’s experience and assume that their dream had some role in the life
and death situation in which they found themselves in ICU. If the only recollection is not a story but a powerful image,
such as a tree, it is worth holding onto it and honouring it.
In each of the above examples
of dreamwork, the dreamer is helped to move from being caught up in the storyline, imagery and strong emotions of their vivid
dreams and/or hallucinations to processing it consciously and gaining a sense of their own powerful attempts to fight for
survival. In my professional experience, making satisfactory sense of ICU dreams not only helps the patient move from fear
to empowerment, but also seems to help prevent the dreams from becoming distressingly intrusive and repetitive.
From
nightmares these dreams can become an empowering testimony to patients’ own resourcefulness. What is more,
they can help give some meaning to their ICU experience: patients may not remember events or medical/nursing interventions
that occurred in that ‘lost time’ while they were in ICU, however these dreams and their significance
can be integrated within the narrative of their coronavirus journey and, if their wish, the story of their life.
Lewes, May
2020
Laura Barnett, MA (Oxon), MA, UKCP Reg., MBACP (Sen.Accred.),
EAP Reg.
References:
Barnett, L. (2006) A Neglected
Client Group: patients who have been in Intensive Care,
in
Therapy Today (2006), 17, 4: 19-21 Rugby BACP Publications.
-- (2006) Working with Patients
who have been in Intensive Care, an existential
perspective, in
Therapy Today (2006), 17, 5: 33-5 Rugby BACP Publications.
-- (2009) Surviving Intensive
Care in Barnett, L. (ed.) When Death enters the Therapeutic Space, (2009), London: Routledge
Boss,
M. (ed.) (2001[1987]) Heidegger, M. Zollikon Seminars, Seminars, Protocols,
Conversations, trans. Mayr, F. and Askay, R., Evanston: Northwestern University Press.
Ogden,
P., Minton, K., Pain, C. (2006) Trauma and the Body. A Sensorimotor approach to therapy, New York: Norton
Righy, C., Rosa, R.G., da Silva R.T.A. et al. (2019) Prevalence of post-traumatic stress disorder
symptoms in adult critical care survivors: a systematic review and meta-analysis. Crit. Care, 23, 213. https://doi.org/10.1186/s13054-019-2489-3
