“Sleep is the golden chain that ties health and our bodies together.” — Thomas Dekker, 1625
“Without enough sleep, we all become tall 2-year-olds.” — JoJo Jensen, Dirt Farmer Wisdom, 2002
“I love sleep. I’d sleep all day if I could.” — Miley Cyrus, 2019
To me, making those elusive connections between events, experiences and symptoms in our clients’ lives is one of the most exciting parts of counseling. There may be no clearer connection between the mind and body than sleep.
How do you sleep? More importantly, do you know how your clients sleep? When we evaluate our clients’ histories and experiences, one area of behavioral health that is easy to ignore or minimize is sleep. But disturbed sleep is very common among Americans and is connected to many psychological and physical health problems later in life. A more comprehensive assessment may lead to important clues about an experience of early trauma and abuse.
Sarah: Initial assessment
As a consultant at a hospital sleep disorders center in Arizona, I saw “Sarah,” a 30 year-old Hispanic woman who was referred because of severe insomnia. She reported great difficulty falling asleep, and even after she did, she often slept no more than three hours per night, with frequent awakenings.
Sarah was married, had no children and worked as a university professor. She claimed that her marriage was “strong and supportive,” and she greatly loved her work as a professor. She had been prescribed benzodiazepine sleeping medications two years prior, but they were no longer helping, and Sarah feared she was becoming dependent on them.
Sarah was in good physical health but was concerned that she had gained 35 pounds over the course of five years. She had never before seen a mental health professional. Her prior overnight visit to the hospital sleep disorders center had revealed major difficulties in initiating and maintaining sleep. Polysomnographic results confirmed that she took 82 minutes to fall asleep initially and that she experienced five awakenings of greater than 20 minutes each during the night. Her total sleep time was 2.7 hours.
Her sleep problems had been present and worsening since high school, or a span of about 15 years. She presented with severe daytime sleepiness, anxiety and depression. Sarah stated, “I can’t go on like this.”
Studies from the Centers for Disease Control and Prevention (CDC) reveal the following data about healthy sleep duration (with higher percentages indicating healthier durations):
Geography: Prevalence of healthy sleep duration ranged from 56% in Hawaii to 72% in South Dakota.
Percentage of healthy sleep duration by race/ethnicity: Native Hawaiian/Pacific Islanders (54%); Black (54%); Other/Multiracial (54%); American Indian/Alaska Native (60%); Asian (63%); Hispanic (66%); White (67%)
Although requirements vary slightly from person to person, most healthy adults need seven to nine hours of sleep per night to function at their best. Children and teenagers need even more. Despite the notion that our sleep needs decrease with age, people older than 65 still need at least seven hours of sleep per night. Interestingly, the average total nightly sleep duration fell from approximately nine hours in 1910 to approximately seven hours in 2002.
Prevalence of disturbed sleep
Sleep disturbance is a common problem that affects at least 75% of Americans at some point in their lives. Among the various sleep disorders, approximately 33% of all adults suffer from an insomnia disorder, which can have significant negative consequences if left untreated. Individuals who struggle with chronic insomnia often describe their condition as a “vicious cycle,” with increasing effort and desire put into trying to regain sleep, with negative results.
A 2014 survey conducted by the National Sleep Foundation reported that 35% of American adults rated their sleep quality as “poor” or “only fair.” Difficulty falling asleep (onset insomnia) at least one night per week was reported by 45% of respondents. In addition, 53% had experienced trouble staying asleep (early awakening or maintenance insomnia) at least one night of the previous week, and 23% had experienced trouble staying asleep on five or more nights. Research suggests that sleep problems are worse among women but increase in both genders with age.
Any of us can do a self-assessment of our sleep deprivation, also known as “sleep debt.” You probably have sleep debt if you 1) find yourself drowsy or sleepy during the day, 2) frequently need an alarm clock to awaken and 3) fall asleep very rapidly (less than five minutes) when you go to bed.
Insomnia is not a disease; it is a symptom. It may be 1) associated with medical problems, 2) associated with psychological problems, 3) due to lifestyle, 4) caused by poor sleep habits or 5) any combination of the above.
Sleep deprivation can have many effects, both physically and psychologically. In the short term, it can lead to stress, somatic problems, cognitive difficulties, anxiety and depression. Long-term effects can include cardiovascular disease, obesity, diabetes, cancer and even early death.
Hypnotic medications are frequently used to treat insomnia, but many patients prefer non-drug approaches to avoid dependence and tolerance.
Assessment of sleep disorders
The self-administered Pittsburgh Sleep Quality Index assesses seven components of sleep based on clients’ self-reports. This widely used instrument has been shown to reliably detect clinical levels of sleep disruption in adults across a broad range of ages. Areas assessed include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications and daytime dysfunction.
On a more practical level, I have found that having clients keep a simple “sleep log” for two weeks can help to identify sleep problems. I have clients record:
- The time they go to bed
- Medication taken (if any)
- Estimated time to fall asleep (onset)
- Estimated number of awakenings during sleep
- Wake-up time
- Estimated total sleep time
- Sleep quality (0-10 scale)
- Daytime alertness (0-10 scale)
- Level of worry about sleep (0-10 scale)
Sarah: Sleep assessment
Sarah was provided sleep self-monitoring materials to complete over 14 days. Results clearly indicated many awakenings during the night, short sleep times and profound daytime sleepiness. These results were confirmed by polysomnographic data. Assessment results indicated diagnosis of insomnia disorder (780.52/307.42), Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).
Assessment of childhood trauma
Systematic assessment of childhood trauma has evolved since the original study of adverse childhood experiences (ACEs) by the CDC and Kaiser Permanente in the mid-1990s.
ACEs are classified in three different subsets: abuse (physical, emotional, sexual); neglect (physical, emotional); and household dysfunction (mental illness, incarcerated relative, parent treated violently, substance dependence, divorce). These 10 areas can be incorporated into a structured interview, with questions such as “Before your 18th birthday, did you often or very often feel that you didn’t have enough to eat? Had to wear dirty clothes? Had no one to protect you? That your parents were too drunk or high to take you to the doctor if you needed it? Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?” These questions can easily be incorporated into a routine clinical interview.
In a large study, 61% of adults had at least one ACE, and 16% had four or more types of ACEs. Women and members of several racial/ethnic groups were at greater risk for experiencing four or more ACEs. Exposure to ACEs is associated with increased risk for many health problems across the life span.
As counterpoint, Jack Shonkoff, a pediatrician and director of the Center on the Developing Child at Harvard University, notes “there are people with high ACE scores who do remarkably well.” Resilience, he says, builds throughout life, and close relationships are key. This implies that the ACE score for an individual is not a static number, but more dynamic, because personality traits and life experiences can modify the impact of ACEs.
Effects of childhood trauma and abuse on sleep
In a major population-based study in 2011, Emily Greenfield et al. found that three classes of abuse history were highly associated with a greater risk of global sleep pathology:
1) Frequent physical and emotional abuse with sexual abuse
2) Frequent physical and emotional abuse without sexual abuse
3) Occasional physical and emotional abuse with sexual abuse
The most extreme class of abuse — frequent physical and emotional abuse with sexual abuse — was associated with poorer self-reported sleep across many components measured, including subjective sleep quality, greater sleep disturbances and greater use of sleep medication.
Adults who reported frequent experiences of childhood physical and emotional abuse — regardless of sexual abuse — were found to be at especially high risk for global sleep pathology. Regardless of their experiences of sexual abuse, respondents who reported frequent experiences of physical and emotional abuse were over 200% more likely than respondents who reported no abuse to have clinically relevant levels of sleep pathology.
In 2018, Ryan Brindle et al. concluded that “childhood trauma may affect sleep health in adulthood. These findings align with the growing body of evidence linking childhood trauma to adverse health outcomes later in life.” Furthermore, trauma exposure after age 18 and across the life span did not relate to sleep health, suggesting that trauma experienced at a younger age is a more important factor.
Sarah: Trauma assessment
In gathering Sarah’s history during the first several sessions, she reluctantly revealed that she had been sexually molested repeatedly by her mother’s live-in boyfriend between the ages of 11 and 15. He was apparently dependent on alcohol and other drugs, with Sarah stating that he seemed “drunk most of the time.” She recalled that these events occurred “about twice a month” and consisted of mutual (subtly coerced) sexual touching and fondling, including occasional oral sex but no intercourse. Sarah never revealed this to her mother. Sarah’s obtained ACEs score was five. This finding suggested a second working diagnosis of trauma and stressor-related disorder in the DSM-5.
In theory and research evidence, there is a fairly clear link between chronic stress and increased production of the hormone cortisol, which in turn can accelerate inflammation in the body. This may be a factor that can help explain the trauma-sleep connection.
Stress: In discussing trauma and sleep in children, Avi Sadeh suggested (1996) that stress was among the most powerful contributors to poor sleep. This can include significant life changes/events or threats that demand physiological, behavioral and psychological resources to maintain “psychophysiological equilibrium and well-being.”
Cortisol: Cortisol is produced by the adrenal glands, and high levels of physical or psychological distress lead to increases in cortisol secretion. In a study by Nancy Nicolson et al. (2010), emotional and sexual abuse were most closely linked to increased cortisol levels. Childhood maltreatment is also associated with elevated cortisol.
For clients living with stress and insomnia, cortisol levels remain elevated above normal levels, especially during sleep. With sustained levels of higher cortisol, these individuals remain in a state of hyperarousal, even when they’re asleep, thereby disrupting the overall quality and restfulness of their sleep. Chronic “short sleepers” (those who get five to six hours of sleep per night) have higher levels of nocturnal cortisol secretion in comparison with “normal sleepers” (those who get seven to eight hours of sleep per night).
Inflammation: Research by Janet Mullington et al. (2010) indicates that long-term inflammation may be the common factor in many chronic diseases. Social threats and stressors can drive the development of sleep disturbances in humans, contributing to the dysregulation of inflammatory and antiviral responses.
It is hypothesized that trauma-induced insomnia is a direct result of two interacting variables: physiological hyperarousal and self-defeating cognitive activity.
Given that Sarah was suffering from insomnia disorder as well as trauma and stressor-related disorder, it was important to determine which problem needed to be the initial focus of treatment. If we expected that her traumatic history was keeping the insomnia alive, there might have been reason to help her process the trauma first. On the other hand, because her insomnia was having major effects on her mood, concentration and daytime alertness, some justification existed for initially treating her insomnia.
Based on the information obtained about Sarah’s sleep patterns and traumatic history, several evidence-based approaches were used in combination over 11 weekly sessions.
Body scan and breath awareness have both been shown to enhance relaxation prior to sleep. They redirect the mental focus toward the present state of the body and breath. The body scan consists of observing and listening to what bodily sensations are communicating in the moment. It involves noticing areas of tension in the body and inviting these areas to release the tightness.
Breath awareness can consist of slowly accepting the inhale through the nose, deliberately pausing for a moment and then slowly releasing the breath out of the mouth. This regulates the pace of the nervous system and provides an opportunity to mindfully experience the feeling of letting go of what is no longer serving the body. Sarah was provided with audio materials to practice these techniques daily.
Cognitive behavioral therapy for insomnia (CBT-I) is a structured program that aids in identifying and replacing unhelpful thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. CBT-I helps to overcome the underlying causes of sleep problems. It requires the client to keep a detailed sleep diary for one to two weeks. The “cognitive” part of CBT-I teaches clients to recognize and change beliefs that affect their ability to sleep. This type of therapy can help to control or eliminate negative thoughts and worries that keep clients awake.
Sarah recorded her unhelpful automatic thoughts and beliefs about her sleep. These included “Not sleeping well is ruining my life”; “I have to fall asleep right now”; “I’m never going to get over this sleep problem”; and “I am worried that I have lost control of my abilities to sleep.” The A-B-C-D-E system (activating event, belief, consequence, disputation, new effect) was explained to her, and she was instructed in ways to dispute and replace unhelpful thoughts and beliefs. She was successful in describing and challenging these thoughts.
Acceptance and commitment therapy (ACT) is a more recently introduced form of psychotherapy that focuses on mindfulness and acceptance in clients with trauma histories. The underlying theory of ACT is that posttraumatic disorders result from attempting to avoid a past experience at all costs. Thus, a goal of treatment with ACT is to develop more accepting and mindful attitudes toward distressing memories and negative cognitions rather than avoiding them.
Sarah was first introduced to mindfulness as a way to reconnect with the present moment. This built the foundation for increased exposure to avoided thoughts and emotions. Through daily mindfulness practice over 10 weeks, Sarah was able to become aware of painful thoughts that were getting in the way of her sleep and mood. Defusion strategies helped Sarah learn to acknowledge these thoughts as “just thoughts.” Defusion is the separation of an emotion-provoking stimulus from the unwanted emotional response as part of a therapeutic process (think of it as being similar to “defusing” a bomb). Unlike strategies that are more cognitive in nature, the goal is not to challenge thoughts, but rather to acknowledge when thoughts are not helpful, detach from them and move forward. It is not necessary to determine if the thoughts are true or untrue.
One major difference between these two approaches is how unhelpful thoughts are handled. In classic CBT therapy, clients are encouraged to dispute these thoughts and replace them with more helpful ones. In ACT, clients learn to recognize and accept their thoughts but to stand away from them, as is used widely in mindfulness practices.
Outcome of Sarah’s treatment
Following our 11 sessions together, Sarah reported the following:
Although average sleep onset time had decreased only slightly (82 minutes pretreatment to 68 minutes post-treatment), her total sleep time had increased from 2.7 hours to 5.3 hours per night, and her number of awakenings decreased from an average of five per night to one to two per night. She also reported significantly less depression and much more daytime alertness. She was able to go back to work as a full-time university professor.
Summary and takeaways
I have reviewed some important research findings about a potential link between childhood maltreatment and adult insomnia. A case study is presented to help clarify methods for identifying and treating these issues.
In working with people with insomnia over the past 10-plus years, it has become apparent to me that a) many clients who suffer from insomnia do not have (or at least do not disclose) a history of childhood abuse or neglect, and b) among clients who do have a history of abuse as children, some have no apparent sleep problems. Regardless of these outliers, it is clear that sleep patterns should be explored in some depth, and it would be sound clinical practice to always inquire about your clients’ sleep patterns.
David Engstrom lives in Scottsdale, Arizona, and is a core faculty member in the clinical mental health counseling program at the University of Phoenix. A counselor and health psychologist, he is an American Mental Health Counselors Association diplomate in integrated health care. He specializes in weight management, sleep disorders and pain management and is on the medical staff at Honor Health Scottsdale Medical Center. Contact him at David.Engstrom@phoenix.edu.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
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