Sleep in the aftermath of trauma

• What is the individual’s sleep environment like? Is it conducive to sleep?
• What are the current sleep patterns e.g., time to sleep, time at waking, and periods of time spent awake during the night? How much sleep, on average, does the individual have each night?
• Periods of sleep during the day? Does the individual “catch up” with napping during the day?
• How much exercise does the individual take? When does exercise occur?
• What is the individual’s use of caffeine/stimulants, alcohol, nicotine, and sleeping pills?
• Does the individual have a routine before going to bed?
• Does the individual spend significant amounts of time in bed awake? Do they worry and ruminate during those times?
• Does the individual have nightmares? Are they disaster or trauma related?
• Does the individual suffer from medical conditions that may impact sleep such as sleep apnoea, chronic pain, or heart disease? Are these well managed? Is referral to a General Practitioner warranted?
• Is the individual suffering from frank mental health conditions that may be impacting sleep? Is referral to a mental health specialist warranted?

Recommend sleep monitoring, either with the use of the sleep monitoring form or by the use of a sleep monitoring App. Information obtained may provide direction regarding the kind/s of interventions most likely to target the individual’s specific sleep difficulties. For example, poor sleep habits may be best addressed with education about good sleep habits, long periods of time spent in bed awake might respond to the use of sleep restriction strategies, while nightmares might be best addressed with the use of Imagery Rehearsal Therapy, implemented by specialist mental health practitioners. Ideally monitor for one week prior to commencing treatment, to establish a baseline. Continue monitoring throughout the intervention period to gauge the success or otherwise of strategies employed. Adjust interventions if improvement does not occur.

1. Provide psychoeducation about sleep

Many people have limited understanding of realistic expectations about sleep needs, or the kinds of factors that may negatively impact sleep, in particular in the aftermath of disaster. Psychoeducation about sleep needs and the impacts of disaster on sleep can be helpful, and health practitioners may find the information in the following handout useful as a basis for discussion (link). Note page 1 of what is currently called “Sleep handout” needs to be separated from page 2, and renamed “All about sleep”.

2. CBT – insomnia

CBT – I is an umbrella term that incorporates a range of strategies designed to target different ways in which sleep can be disturbed.

Education about healthy sleep habits:

Discussions about health sleep habits should attend to environmental and physiological factors, as well as personal habits that promote effective sleep. Discuss the sleep environment and encourage changes that may be more conducive to sleep such as keeping the bedroom dark, quiet and cool, removing televisions and computer screen, removing the clock from view. Discuss basic behaviours and lifestyle habits that may influence sleep such as caffeine, nicotine and alcohol consumption, inadequate or poorly time exercise.

The use of stimulus control:

Stimulus control techniques aim to develop a positive association between the bed and sleeping. It conditions the individual to expect that bed is for sleep only (the exception being sexual activity), rather than other stimulating activities such as television watching and paying bills on the laptop. The individual should be instructed to go to bed only when sleepy, and to leave the bedroom if unable to achieve sleep after around 15-20 minutes (this should be estimated, not based on clock-watching). Upon becoming sleepy again, he or she may return to bed. This should be repeated as necessary until sleep is achieved.

Sleep restriction techniques:
Individuals experiencing sleep difficulties may spend significant periods of time in bed when they are not actually asleep. Thus, sleep becomes fragmented. Sleep restriction aims to reduce the time that individuals spend in bed not actually sleeping, or in other words, to increase their sleep efficiency. The sleep efficiency goal is 85%, meaning that people are asleep 85% of the time that they’re in bed. These are the steps to work through to achieve this:

1. From the sleep diary, work out the average amount of actual sleep per night (not including the time spent lying in bed awake). The goal is to stay in bed for only the length of calculated average sleep time.
2. Encourage the individual to choose a regular wake up time and stick to it every day, even weekends.
3. They should then set their bedtime by starting from the wake up time and subtracting average sleep time. For example, if the selected wake time is 7am and the person’s average sleep time is 6 hours, their bed time would be 1am.
4. Have the person continue monitoring their sleep and after a week, calculate sleep efficiency again (number of hours sleep/time in bed). If sleep efficiency is 85% or higher, they can increase time in bed by 30 minutes, so for the next week their bedtime would be 12.30am.
5. Repeat this process each week, increasing time in bed by 30 mins per week so long as sleep efficiency stays at 85%. If sleep efficiency drops back (i.e., they’re spending more time awake during the night), reduce the time in bed by 30 mins at a time until sleep efficiency gets back to 85% then gradually increase again.

Sleep restriction will increase tiredness at first, and people need to be encouraged not to sleep past their chosen regular wake up time, even if they’re still tired when they wake up in the morning. Over the course of a month or two, a new and sustainable sleep schedule will be established.

Cognitive therapy:

Cognitive therapy aims to identify, challenge, and replace unhelpful beliefs and attitudes regarding sleep and sleep deprivation. These commonly include an overestimation of the amount of sleep necessary to feel rested, believing that sleep cannot be controlled, or fears around missing opportunities for sleep. These kinds of beliefs can also hinder adherence to sleep restriction and stimulus control techniques.

It may also be helpful to address sleep’s relationship to anxiety, in particular after disaster. Cognitive therapy can help individuals challenge anxious thoughts, and develop more helpful alternatives. Explain how worry and rumination (thinking of negative things over and over again) can become more prominent after disaster, and when it occurs at night it can make sleep more difficult. Consider reviewing the module that explores strategies to assist with the management of anxiety, worry and rumination (link). Individuals are less capable of problem solving at night, and it may be more helpful to set aside time for worrying, anxious thoughts, diary keeping of fears, and problem solving, during the day. These activities should be reserved for during the day when cognitive capacities are available to think logically and utilise hindsight and perspective.

Relaxation techniques:

Post disaster anxiety, worry and rumination may also impede sleep because it results in the body experiencing high levels of arousal (the fight-flight system) which is not conducive to relaxation (the rest-digest system) and sleep. Encourage regular use of tension reduction and other relaxation therapies such as controlled breathing, and Progressive Muscular Relaxation. Consider reviewing the module entitled “Managing Difficult Emotions” that explores self-help techniques designed to reduce distress (link). Daily practice and use of these techniques can also enhance the individual’s sense of self-control. Encourage individuals to consider using a range of free-to-download apps for smartphones and androids designed to assist with relaxation and sleep. Other useful apps are available but may involve a fee. Encourage individuals to adopt a trial and error approach as they explore various options until they find the strategies most helpful for them.

Ultimately, careful attention to the information provided by completion of the sleep diary will give both health practitioner and disaster-impacted individual direction regarding the strategies that might best address their particular sleep difficulties.

3. Imagery rehearsal therapy

Explain that nightmares can lead us to avoid sleep which can make mental health worse. Explain that reducing nightmares is one of the goals of Imagery Rehearsal Therapy for nightmares, a technique that directly targets post traumatic nightmares. This technique typically involves a number of elements:

• Psycho-education about sleep and nightmares generally
• Modification of the nightmare narrative and sensory detail to be less threatening
• Regular rehearsal in the mind’s eye of the modified nightmare in all of its sensory detail.

Some forms of the approach also include identification of trauma-related themes within the nightmare, and exposure to the nightmare itself, for example by recounting the content of the nightmare to the therapist in individual therapy or to others in a group therapy context. The identification and modification of meaning, a cognitive element, and the inclusion of exposure to the modified nightmare, a behavioural element, sit well within an overall CBT treatment framework and are consistent with the treatment rationale and strategies employed within a CBT-I approach to the treatment of insomnia. For those interested in Imagery Rehearsal techniques, the full manual for the therapy is included here (link).

Establish realistic expectations for change. Depending on the chronicity of sleep disturbances, changes may take several weeks to become obvious. In some cases, for example with the use of sleep restriction techniques, sleep may get worse before it gets better.

Ongoing monitoring may allow the individual to note continued engagement in activities not conducive to change, as well as small changes in the desired direction. Continue to encourage completion of the sleep diary in order to monitor outcome of interventions. Subsequent referral to a sleep specialist will involve a request for a sleep diary so it will be helpful for the client/patient to begin this even if the problem is serious enough to require referral. In addition, a sleep diary allows the client/patient to manage expectations (they might find out they are actually getting a good deal of sleep) and to make behavioural changes which help.

For some people reactions following disaster may fluctuate, and other issues may emerge over time. Be alert to this possibility and continue to assess. Be open to the need to refer to a general practitioner or specialist mental health practitioner.

Recommended reading list:

• Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2006). Cognitive behavioral treatment of insomnia: A session-by-session guide (Vol. 1). Springer Science & Business Media. Available as an e-book
• Phelps, A. J., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic nightmares: An empirical and conceptual review. Clinical psychology review, 28(2), 338-355.