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

Trainee-run free clinics are a familiar fixture of American medical education, particularly in primary care. They give students early, hands-on exposure to real clinical decision-making while extending services to communities that fall through the cracks of the insurance system. Yet psychiatric care has lagged behind. As the authors note, opportunities for trainees and residents to lead psychiatric services in free-clinic settings remain limited compared with the well-documented landscape of student-run general medical clinics. The gap matters doubly, because mental health need among uninsured and underserved populations is high while access to culturally competent psychiatric evaluation and medication management is scarce.

The impetus for the new clinic emerged from unmet needs on both sides of the examination table. At the host trainee-run general medical clinic, patients frequently reported untreated depression, anxiety, and insomnia during their primary care visits, with no psychiatric service available to address them. At the same time, an internal survey of thirty-two medical students revealed a strong desire for earlier and more substantive exposure to psychiatric practice, and psychiatry residents expressed interest in community-based care and teaching opportunities. Many patients in the clinic population are Spanish-speaking and face cultural stigma surrounding mental illness, making culturally attuned psychiatric care particularly important. Together, these converging pressures convinced the trainees that a dedicated free mental health service was both necessary and feasible.

In February 2025, the team founded the clinic in partnership with Now-Forward, formerly known as North Dallas Shared Ministries. The design process began with deliberate stakeholder engagement: the founders gathered input from medical students, residents, attending physicians, and community partners to shape the clinic’s structure and workflow. That process surfaced an instructive history. A previous consulting psychiatric service operating within the host clinic’s general medicine clinic had been discontinued in 2020, undone in part by a mismatch between patient complexity and trainee experience and by a clinical scope too narrow to allow meaningful follow-up. Rather than revive that model, the team designed a stand-alone monthly mental health clinic built specifically to correct its weaknesses.

The structural solution centers on matching patient complexity to trainee seniority. The clinic team includes psychiatry residents in postgraduate years two through four, alongside medical students and attending psychiatrists, so that the most medically complicated patients are not left to the least experienced volunteers. Supervision and malpractice coverage are provided through existing federal and institutional mechanisms, and residents may only volunteer with attending supervision and institutional approval. Before each session, residents and experienced student leaders orient volunteers to common patient presentations, cultural considerations, and clinic workflow. Bilingual residents and medical students serve as interpreters for Spanish-speaking patients, a practical response to the language barriers that pervade the patient population.

Clinically, the service focuses on the diagnosis and treatment of depression, anxiety, and insomnia through comprehensive psychiatric evaluation, medication management, and referral to community resources. Patients whose conditions require a higher level of care, such as psychotic disorders, mania, or eating disorders, are referred to other psychiatric services rather than managed in the free-clinic setting. Referrals flow from primary care clinicians within the host clinic or arise from systematic screening using the PHQ-9 depression and GAD-7 anxiety instruments during primary care visits. Student coordinators then contact eligible patients to schedule appointments in the monthly psychiatry clinic. Between sessions, those coordinators conduct follow-up calls, assist with scheduling, and coordinate additional needs with the host clinic, creating a continuity infrastructure that the earlier consulting model lacked.

Implementation was anything but frictionless. Faculty credentialing, conflict-of-interest documentation, and coordination with residency leadership were all essential to ensure regulatory compliance, and the authors are explicit that residents cannot simply volunteer without attending supervision and institutional sign-off. Patient recruitment initially proved difficult but improved after the team moved clinics to Saturday mornings, incorporated telehealth visits, and coordinated more closely with the host clinic’s primary care team. Since February 2025, the clinic has held twelve sessions, typically serving one to four patients per session, approximately seventy-five percent of whom are Spanish-speaking. The modest per-session volume reflects a deliberate trade-off: careful supervision, thorough evaluation, and continuity take precedence over throughput.

The educational payoff, the authors argue, has been substantial. For many trainees, these encounters were their first experience taking responsibility for continuity of patient care. Patients arrived seeking optimization of antidepressant and sleep regimens, clarification of long-standing diagnoses, and guidance through fragmented systems of care, often carrying burdens of trauma, limited health literacy, language differences, and competing social or occupational demands. Careful reassessment sometimes led to diagnostic clarification and the identification of previously unrecognized psychosocial contributors, an experience the authors connect to prior evidence that managing real, complex patients improves patient-centered clinical reasoning. The clinic also functioned as a site for professional identity formation and competency in team-based care: the trainees coordinated with the host clinic’s psychotherapist for shared patients and offered resources for therapy, social, and religious engagement aligned with each patient’s identity, goals, and values.

Perhaps the deepest lesson concerned the nature of psychiatric care itself. Working within a recovery-oriented framework, the trainees came to see that psychiatric treatment is more than episodic symptom management; it requires a longitudinal commitment within a broader social context. Many patients had trauma histories that shaped their willingness to engage with treatment, underscoring the importance of trust, continuity, and attunement to individual experience. Whenever possible, returning patients were scheduled with the same medical student, resident, and attending to strengthen rapport across visits. The trainees observed that patients often sought clarity and validation as much as medication adjustments, and several expressed relief at finally accessing mental health care after prolonged difficulty navigating existing systems, a reminder of the therapeutic value of a consistent, attentive presence.

The authors acknowledge that their report reflects the experience of a single site, but they present it as a replicable framework for institutions seeking to expand psychiatric service and learning opportunities. The most transferable elements, they argue, are embedding psychiatric care within an established free medical clinic and incorporating psychiatry residents to better match patient complexity with trainee experience. Future work, they write, should explore longitudinal patient outcomes and the role such clinics play in shaping trainee attitudes toward community psychiatry and public service. For a specialty confronting a national shortage of psychiatric access, the Dallas experiment suggests that the next generation of psychiatrists may be ready to help close the gap, provided institutions are willing to supply the supervision, credentialing, and infrastructure that responsible trainee-led care demands.

Subject of Research: Establishment and educational value of a trainee-run free mental health clinic for uninsured patients

Article Title: Establishing a Trainee-Run Free Mental Health Clinic

Article References: Establishing a Trainee-Run Free Mental Health Clinic. (n.d.). https://doi.org/10.1007/s40596-026-02438-1

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02438-1

Keywords: trainee-run clinic, free clinic, psychiatry, mental health access, medical education, uninsured patients, Dallas, depression, anxiety, community psychiatry, PHQ-9, bilingual care