Friday, August 14, 2009

Trauma, Sleep Disorders and Treatments

I've been learning about how sleep disorders are often another health problem associated with violent victimization. To be honest, I had not thought much about how violent trauma may change survivors' sleep before now. Maybe this is true for others too? So I thought a brief summary of research on this topic may be useful to share with others here.

Though limited research has been conducted in this important area, the existing research shows an association among Post Traumatic Stress Disorder (PTSD), sleep disorders, and the experience of violence (see Kendall-Tackett's 2007 research). Violence survivors with PTSD are likely to struggle with sleep problems (see Caldwell's & Redeker's 2005 research).

Such sleep disorders may resolve once a survivor receives physical and behavioral care interventions that address disorders that underlie or exacerbate sleep difficulties such as chronic pain, substance abuse, depression, and PTSD. However, this resolution is not true for all survivors with sleep disorders, and many survivors will benefit from specialized sleep treatments.

When a violence survivor is identified in a physical or mental health care practice, Caldwell and Redeker recommened that the clinician should use a sleep hygiene checklist to assess the patient’s sleep. When paired with education about effective sleep hygiene, such assessments may improve a survivor’s sleep patterns. However, providers should also refer survivors to sleep centers if the survivor’s sleep patterns do not improve with either the implementation of sleep hygiene strategies or treatment for other health disorders.

Evidence-Based Mental Health Treatments for Violence Survivors

Advocates and human service providers may be interested to know that there are two behavioral therapies for violence survivors with Post Traumatic Stress Disorder (PTSD) that are supported with promising, positive findings from randomized controlled trials.

These two empirically supported therapies are based in cognitive-behavior therapy (CBT) theory. To help readers understand these therapeutic approaches, I provide a description of CBT.

Briefly, the theory of change underlying CBT posits that difficulties in human functioning stem from inaccurate, unhelpful beliefs or thoughts (i.e., cognitions) about the self, relationships, the world, and the future. A cognitive-behavioral therapist uses psychoeducational techniques, modeling, in-session therapeutic exercises, and between session homework to build a client’s cognitive change, emotional regulation, and behavioral skills in ways that address the client’s presenting problem. CBT has been widely researched and determined to be an effective practice with a range of presenting problems, including depression, anxiety, PTSD, chronic pain, and substance abuse.

Prolonged exposure is one of the most researched treatments for PTSD, and it has repeatedly demonstrated efficacy in the treatment of PTSD caused by various traumas, including women who have survived violent physical and sexual assaults (see Foa and colleagues’ research from 2005).

The prolonged exposure approach seeks to improve PTSD symptoms by using two therapeutic strategies. First, the therapist- in the context of a safe place and in a therapy session- has the survivor repeatedly imagine the traumatizing, violent event. Second, the therapist may have the survivor expose herself to real life situations that she tends to avoid because of the violent event. For example, the violence survivor avoids walking down a street in her community because that was the palce where she was attacked. This street would then become a site for real life exposure, either as part of a therapy session or as part of homework that the survivor would do outside of therapy sessions.

Prolonged exposure is usually delivered in 9 to 12 individual therapy sessions that are 1.5 to 2 hours in length. This therapeutic approach is implemented most effectively when (a) the therapist and client have established a strong therapeutic alliance; (b) the therapist has provided the client with a clear rationale for the treatment; (c) the therapist has successfully conveyed to the client both the potential usefulness of the treatment, and the therapist’s expertise in delivering the treatment; and (4) the treatment is tailored to the client’s situation and symptoms (see Hembree and colleagues 2003 article for how to implement this therapy). Moreover, prolonged exposure should be delivered when violence survivors are no longer in danger and are living safe, violence-free lives.

Second, Kubany and colleagues developed Cognitive Trauma Therapy for Formerly Battered Women (CTT-BW) based on the evidence regarding the effectiveness of CBT-based therapies for individuals with PTSD. Specifically, these researchers sought to develop this therapy because no such interventions specific to survivors of partner violence had been developed and rigorously evaluated.

CTT-BW is described as “a multi-component, cognitive-behavioral intervention aimed at alleviating PTSD, depression, guilt and shame, and elevating self-esteem in formerly battered women” (Kubany & Watson, 2002, p. 113). CTT-BW is usually delivered in 8 to 10 individual therapy sessions lasting 1.5 hours each. The sessions are conducted twice a week, and clients work on therapeutic homework between sessions. The therapeutic strategies of CTT-BW include (a) providing psychoeducational content about PTSD, (b) teaching stress management, (c) developing a woman’s cognitive skills to enable her to monitor and to modify unhelpful beliefs, and (d) imagined and in vivo exposure to the trauma.

Similar to prolonged exposure, CTT-BW is appropriate for women who are no longer in abusive relationships and who are relatively safe. Although the use of CTT-BW has led to improvements in PTSD symptoms among battered women in a randomized controlled trial (see Kubany and colleagues' 2004 research), limited experimental evidence exists for this therapy approach and additional research is warranted to establish the treatment’s efficacy.

This information may be helpful for advocates when they refer survivors to mental health therapist. Advocates may want to ensure that the therapists who they use as referal sources for survivors have training in evidence-based mental health therapies such as these.

Likewise, mental health therapist who work with violence survivors may want train in these therapies.