Healing Sleep: Navigating Trauma And Sleep Medicine

Lara Barbir, PsyD

Thank you. Very grateful to be here.

Audrey Wells, MD

Now, I will tell you, I think that the aspects of trauma that affect sleep are not talked about as much as they should be, because in my experience, they are quite common, and having unresolved trauma, PTSD, or even just anxiety can impact a person’s ability to sleep well. Is this something that you see a lot in your practice?

Lara Barbir, PsyD

Absolutely. There is quite a complicated relationship between trauma and sleep as well. I am again very appreciative that you are including this as part of your discussion. It is very important to consider sleep issues from all angles, and trauma is a big one. Of course, there is a complicated relationship where sleep certainly can affect trauma, its many sequelae, and how it presents itself. Of course, trauma and PTSD can also affect sleep.

Audrey Wells, MD

I think some people are not quite sure what treatments might be available to address the root causes of trauma or chronic anxiety. One of the things that you are passionate about is EMDR and interpersonal psychotherapy. I wonder if you can describe how these modalities can improve a person’s situation, particularly as it pertains to sleep.

Lara Barbir, PsyD

Absolutely. I will certainly start with EMDR, which stands for Eye Movement Desensitization Reprocessing. It is a type of trauma-focused therapy. I particularly like this one in that, compared to some of the other trauma-focused therapies, which are solely talk therapies, it has a bit more of a non-verbal and a somatic component in the way that we experience trauma, which is often largely happening pre-verbally and/or non-verbally and thematically. There is something unique about it in comparison to other trauma-focused approaches. It works from the idea that any of the present-day symptoms or issues that we are experiencing, including sleep issues, anxiety, and the many different ways they present themselves in our day-to-day lives, at work, in our personal lives, in our relationships, and other domains of life, including physical pain. 

What EMDR theorizes is that those present-day issues that are coming up are these unresolved earlier experiences that are coming up and being triggered in the present moment. By using EMDR techniques, we can help go back, look at, and fully resolve those disturbing experiences that are getting triggered in the present day so that they can be removed altogether. Of course, if this is taken care of, that has a trickle-over effect on our functioning and certainly our sleep. What happens for many people, whether they have full-blown post-traumatic stress disorder or just anxiety, chronic, trauma-related anxiety? A big feature is avoiding or avoiding facing some of their triggers, whatever is triggering those current symptoms. Targeting that avoidance and helping someone fully confront it, is going to allow them to sleep better. 

Because sometimes the impact that unresolved trauma has is that we get good at staying busy and being high-functioning to the point of maybe overfunctioning. Then, when we hit the pillow at night, all those recurring or intrusive thoughts, images, and memories just start invading our brain, and it can affect our ability to fall asleep. Or we can be so exhausted that we fall asleep, but in the middle of the night, we might have dreams that are recurring, leading into borderline nightmares that impact our ability to get quality sleep. then, of course, that continues to worsen or maintain itself the more we avoid it. I would certainly say that EMDR therapy has a direct impact, of course, on being able to get better sleep through its many techniques. 

Relatedly, and why I tend to also integrate into their psychotherapy, many people come to me, and what tends to motivate most people to come to therapy to try to make huge lifestyle changes is love and relationships. Interpersonal psychotherapy is an approach that can be used across all sorts of problems, including PTSD, even though it is not specifically a trauma-focused therapy. It has this idea that by helping improve the quality of our relationships, it can enhance our quality of life and reduce any of the distress that we experience. It takes more of an approach to examining our social circle as it is present day, seeing that in the context of perhaps changes that we have been through, as most people tend to initiate therapy at a time when there are some psychosocial stressors, relocating, a change in relationship status, etc. so that tends to exacerbate some of the symptoms that were laying dormant, which then leads them to come to therapy. 

We do more exploration about the stressors and their current relationships, and then look at communication patterns and how those relationships that may have changed once helped them get their needs met and helped improve the quality of their relationships through improved communication. Often looking at some of the blocks to communication, which are often trauma-related. That is where I tend to also integrate EMDR therapy, and I find the two to supplement one another very well. Once we can increase and have better social support, we are social animals as humans. This is going to have a positive impact on our sleep quality because it is going to reduce our anxiety and depression, help us feel more connected, and, of course, be able to, again, be less avoidant of particular things that might be triggering our distress.

Audrey Wells, MD

There is great information there. I want to go back and highlight a couple of the things that you said. You mentioned that some of the traumas that we accumulate happen in a pre-verbal state. I translate that to mean that these are things that occurred as children when we were not able to name what was going on or maybe even understand what was going on very well. then it also tends to happen automatically early in the body is how I translate that. I am wondering if there is a bidirectional effect between trauma and sleep. Trauma can impact your sleep negatively. But one of the functions of sleep is to process emotions and even dampen emotions. That vector runs both ways. For someone who is dealing with trauma as you are working with them, I wonder if you notice any reports back about sleeping more or having more intense dreams—things that are helping move them along in their trauma journey.

Lara Barbir, PsyD

Such a great question. Such a great point. Yes, to your earlier reflection, a lot of trauma does happen preverbally, which many of the clients I can recall and look at, and it can also occur more when language is accessible. yet though there maybe is not a language for their emotions depending on upbringing and how emotionally intelligent savvy available mature their caregiver or caregivers are. The sleep impact on yes, sorry, I am drawing a blank on your second question.

Audrey Wells, MD

That is okay. It was stacked. I am just thinking about, when I am talking to somebody about their PTSD or trauma, interrupting their sleep. One of the things that I try to highlight is that they may see increased sleep or a greater need for sleep as they go through therapy or different modalities to process that trauma.

Lara Barbir, PsyD

Yes, thank you. Thank you for that reminder. I certainly am, of course, in a new environment. Last night, I slept in Joshua Tree, enjoying the new moon. Of course, when you go somewhere for the first night, it is normal to not sleep as well because it is just our survival instincts. That is my brain today, and all but I will certainly agree with the impact that trauma therapy essentially has on sleep. Anecdotally, I have noticed many patients reporting in the context of trauma-focused therapies. EMDR, which I tend to have a bias toward, but also other trauma-focused therapies such as cognitive processing therapy, prolonged exposure therapy, and written exposure therapy. A lot of the other deemed gold-standard treatments for PTSD tend to increase the experience of dreams and nightmares. 

In the course of treatment, especially in the initial phases, because this tends to be true across the board for just what therapy tends to look like for people who initiate psychotherapy, we typically say that the process is not linear. It tends to get worse before it gets better because it comes back to the avoidance that I mentioned earlier. We have gotten so good at being able to compartmentalize, minimize, deny, and intellectualize all forms of denial and avoidance. That trauma, of course, when we start to bring it up, is like shaking a soda bottle. soda bottle and just opening up the can. A lot is going to come out first. that tends to impact people in multiple ways. But intrusive experiences can happen while they are conscious, unconscious, or during their sleep. 

What EMDR therapists often tell their clients is that even though we will just do the reprocessing during the hour-long session that we have together, you may notice the processing continuing, which can come in the form of just spontaneous insights or connections during the daytime, or it can be dreaming trauma-related content or something thematically related. That is what I tend to find, certainly because of the somatic component as well. People may also notice physical manifestations. Well, whether that be just general feelings of heaviness or fatigue, which are of course somatic expressions of depression, that need to come out and be released because it is a natural reaction to abnormal things that happened to them. 

Being able to acknowledge, honor, and come out of denial of those feelings of helplessness, powerlessness, and hopelessness is a necessary part of the healing process. They can certainly see that that can also impact healing and other somatic manifestations that people report, which is why I am interested in chronic pain, how chronic pain is also a manifestation of unresolved trauma, and why we need to treat chronic pain from that trauma-informed lens as well. Certainly, though, it does impact their sleep and can affect their desire to sleep longer. That can tend to have an impact, as some might involve more intense dreams, but some might be more conscious. It depends on the person and their unique way of processing.

Audrey Wells, MD

I agree with what you are saying. I have seen that chronic pain is a manifest citation of unresolved trauma. I think of it as carrying this invisible burden and becoming physically as well as mentally or emotionally weary. That is not the same thing as sleepiness, and fatigue from constantly carrying your trauma around is not the same thing as sleepiness. It can be competitive with sleep, as people are lying there in the darkness, in the quiet, with all of their thoughts and feelings. A lot of these things tend to come up and interfere with the ability to sleep. I wonder if you can describe what EMDR looks like, and then I would love to get these benefits of EMDR, because I think that would give a lot of people hope that their trauma could reach a place where they see noticeable changes and benefits in their lives and their sleep.

Lara Barbir, PsyD

Yes, absolutely. The way EMDR works is certainly going to look unique to each person. The good news, though, is that EMDR works on the premise that our brain has a natural ability and desire, and we have an innate desire to heal. Just having the appropriate context that feels safe and being able to access necessary resources—both external resources, which are where interpersonal therapy and tools can help—as well as internal resources, including therapy, therapy tools, and ways of helping you learn how to regulate your emotions in healthy ways—are important prerequisites before starting the reprocessing phase. 

But what I typically tell patients is that there are multiple ways that we can start EMDR, depending on whether they want to target and prioritize specific issues. If that is the primary desire, we will look at what the specific issues are that they want to prioritize. From there, we look at and explore some of the long-term memories that are tied to those issues of prioritization, which will help us identify memories to target for reprocessing. EMDR can be done either in person or through telehealth, so it is very accessible, and if you are doing it in person, often I am just simply helping with my fingers and having a client follow me there. Also, there are light beams and equipment that can be used as well, but it is not necessarily necessary that the idea be just to activate bilateral stimulation. 

This is, of course, as it relates to sleep intended to mirror what happens during the REM, or rapid eye movement stage of sleep, and what we know about REM sleep is that it is a necessary process for memory consolidation and emotional processing. But there are also some other things going on in EMDR that enhance its benefits as well, including, I think, the pre-and-slash-nonverbal component and the somatic component that allow for true consciousness with the present moment as it relates to these unresolved issues. Let us see who has a good picture.

Audrey Wells, MD

Who is a good candidate for EMDR, and when should people expect to see results if they are doing it consistently?

Lara Barbir, PsyD

Yes. Anyone and everyone is a good candidate. Certainly, the prerequisite, as I mentioned, is a willingness as well as making sure to tap into their resilience across physical resilience through their, however, physical activity, exercise, and how they take care of their body through diet and, of course, aiming for ideal sleep, which means treating any other sleep disorders that may be co-occurring. There is a very large link between PTSD and sleep apnea. Of course, by the way, as and so looking across developing physical resilience, their mental resilience, mental and emotional, which we work on in the EMDR context and the therapy space, and spiritual resilience is certainly necessary for addition to social. Those are some of the prerequisites. 

Anybody interested in their personal growth can benefit because the news is that we all have some form of trauma; we are all impacted by our early learning experiences. We can all grow personally by looking at ourselves and looking at these parts of ourselves when we were little. We naturally rejected and looked ahead of ourselves to what some people might label their shadow side or their shadow work. But we all have different sorts of wounds. Anyone can benefit from it. We know that it can, of course, impact our view of ourselves because it is helping us resolve these wounds and be able to look back with a lens of compassion and love rather than shame, fear, guilt, helplessness, powerlessness, and hopelessness. It has a great impact on developing a stronger and more secure sense of ourselves, which affects, of course, our feelings of self-efficacy and helps us tap into our more authentic expression of ourselves. Of course, if we have a healthier relationship with ourselves as we take better care of ourselves through our various habits, that can affect our sleep as well. 

You are wondering, well, how long might EMDR therapy last? It depends. But what the randomized controlled trials show, and this is consistent with my experiences with clients as well as my experience as an EMDR client myself, is that each memory that we target typically takes about a handful of sessions—50 to 60-minute sessions—to fully reprocess. And how we know something is fully reprocessed is that we tend to use a scale of disturbance too, and we bring it up each week with the client. and typically, I would say, do not tend to target more than ten earlier memories with the client. so that can look something over the year, sometimes a little less, sometimes a little more, just depending on various factors. That is a little bit more about what it might look like in the therapy space.

Audrey Wells, MD

Yes, it is so interesting, and I will share that I have tried EMDR therapy. I have done some sessions, and I found them to be remarkable in their effectiveness. I know that many people are quite surprised to have that experience because otherwise, the progression of talk therapy can be quite slow. Then you do something EMDR and experience a breakthrough that can be healing. Some medications have been used for trauma, but the results can be mixed and not necessarily predictable for an individual. I am wondering, besides talk therapy and EMDR, what other trauma treatments do you use or would you recommend?

Lara Barbir, PsyD

That is a great question. Aside from psychotherapy, honestly, I think life can be seen as therapy. I have, even in my own experience, tried to, as a nerd, but I have tried to develop my formula for what has been healing for me. I think about exercise. Exercise is just incredibly important in the sense of moving your body. We are wired; our bodies are wired to move, but also in the sense of being outside, being outdoors, and being connected to nature. Of course, we know that greenery and being connected outside help enhance our senses, which gets us out of our heads and more into the present moment. That is something that is a slight detour, but a necessary one.

I think that something that the talk therapies do is that they might keep those of us who are more intellectual in that intellectual state, and that can be problematic because someone who is very intellectual needs to be less intellectual and more in touch with and connected to their bodies and their emotions. This goes back to why I think exercise is huge. There are many complementary and alternative approaches. Certainly, I would recommend just the best oleander cloaks the body keeps. The score is a great reference. It is certainly dense but a very helpful read that goes through all sorts of complementary and non-talk therapies that can be effective, whether that be meditation, yoga, or tai chi. 

I have my personal meditation practice, and I think gratitude practice is important because our brains are hard-wired to focus on problems and negative things, and we tend to overlook gratitude. Gratitude is something that we therefore have to train our brains to do. A simple daily practice of reflecting on three moments throughout the day that you can appreciate and doing that over time, developing a consistent habit of that has monumental effects. I consider that therapy involves nurturing the relationships that you value where you just naturally feel safe, and then being who you are is incredibly important and honoring things, practices, and daily practices in your life. Just where you feel most alive and connected, I think, can be therapeutic in and of themselves. Then, of course, having a big psychosomatic behavioral medicine, training, background, and my autoimmune disorder, I think just the foods that you consume, in addition to the other types of energy and practices you consume day to day, are equally important. Making sure that you are of course eating, eating your colors, and just striving to eat whole foods is, I think, an important part.

Audrey Wells, MD

I agree. I want to go back to something that you said about people who are in their heads. I love that because that is a lot of the counseling that I do around my mind cannot shut off. I am just spinning in my head. These are the complaints that people have: they are trying to get to sleep. I want to point out that your mind can go into the future and worry about what is to come. Your mind can go into the past, have regrets about what was, and get into a spin that way. But the body is grounded in the present, and honoring that with a somatic meditation in bed or doing some muscle tensing and relaxation in a coordinated sequence can be helpful to get out of your head. But these daytime practices are important as well because how you spend your day affects how you spend your night. I love that you said to get out of your head. It is something that I think a lot of people struggle with. I want to switch gears and talk about nightmares a bit. From your perspective as a therapist, what are nightmares, and how do you approach a nightmare situation when it becomes a problem for a patient of yours?

Lara Barbir, PsyD

The nightmares are the primary concern because there is always a more in-depth assessment on my end. One that often captures my interest is, of course, looking at PTSD and the potential for untreated sleep apnea that is gone undiagnosed. Anecdotally, I have met many patients who present with PTSD, depression, and insomnia. Then it comes to finding out they have this undiagnosed sleep apnea that is causing and/or exacerbating all of those things. When nightmares present themselves to me, I want to make sure and look at the root cause of the nightmares, as I tend to see nightmares as secondary to something else that is going on. Even though the client might be focusing on that as the primary issue. 

I am usually thinking about it from a trauma-informed lens, what has happened to them that might be leading them to develop these nightmares? Or, if I am also thinking from a more comprehensive perspective, is there some substance use involved that could be affecting them? As we know, cannabis withdrawal symptoms certainly include vivid dreams and nightmares, as well as many other substances. But that one has been more heightened by my experiences. I tend to want to rule out sleep disorders and trauma, whether that be full-blown post-traumatic stress disorder or trauma-related symptoms and anxiety that are still clearly clinically significant. 

As somebody who embodies functional medicine or strives to practice from a functional medicine standpoint, I want to get to the roots. That is again why I tend to use EMDR and look at more relational approaches there rather than jumping straight into a nightmare treatment, imagery rehearsal therapy, which, of course, has mixed results in randomized clinical trials. This is why I tend to see it as secondary to something traumatizing or an untreated sleep disorder. If we treat the sleep disorder, we will notice that those nightmares tend to subside. If they do not subside, it is often because they are still on and their PTSD is not being optimally treated. Then we also want to do that.

Audrey Wells, MD

Yes, I cannot tell you how many times I have seen someone who comes in because they have nightmares. I find that they have either sleep apnea or movement disorders during sleep. I think it is interesting when, when I solve that or treat it, the nightmares tend to improve as far as sleep apnea is concerned. One of the things I see commonly is that people feel they cannot get something out of their mouth, they are having a dream about it, or they are pulling something out of their mouth. They are buried alive or drowning. It is remarkable when that happens. For me, that is a huge red flag that there is a breathing disorder going on. It is pretty satisfying to get that treatment. I hear you about the image rehearsal therapy. That has been a mixed bag for me, too. I think finding the root cause is always necessary when you are exploring things that can be secondary, such as nightmares. Do you have the experience that PTSD correlates very strongly with recurrent nightmares, or is that something that is hit or miss?

Lara Barbir, PsyD

That is a great question. I do find that they are certainly strongly correlated. If it is a recurring nightmare, it may not be. It may not. The content of the recurring nightmare may not be directly correlated with the specific trauma, but it might thematically be related. That is something that tends to resolve itself with trauma-focused therapy because if somebody has trauma and they are just wanting the nightmare scripting treatment, which is what imagery rehearsal therapy is, in a nutshell, it is helping somebody consciously rehearse that nightmare and then rewrite the ending of the nightmare for somebody who has untreated or unresolved trauma. If they start to go through a nightmare scripting treatment, it is going to lead to trauma and a need for trauma processing therapy because it is going to open up that trauma. They are going to start having more intrusive experiences, and they are going to need to essentially treat the trauma. That is at least been my experience, and hence why I tend to steer away from going to IoT and doing more of the let us rule out sleep disorders. Treat the sleep disorders first, and then let us go through trauma-focused therapy as necessary.

Audrey Wells, MD

Yes, it makes sense. I understand what you said about the dream content not necessarily being related to the trauma itself. Frequently, I get asked by patients about interpreting their dreams, and I try to keep that at arm’s length. I think dreams can certainly be informative and meaningful to the person who is experiencing them, but I see my role in interpreting those dreams as quite limited. What I hear from you is that the dream itself may be disturbing and reflective in some way of having some unresolved trauma, but it is not necessarily directly related.

Lara Barbir, PsyD

That is correct. Yes.

Audrey Wells, MD

Interesting. I think that as we become more informed about trauma and aware of the impacts it can have, I certainly hope that more people who are dealing with this type of thing can seek help. Do you have any resources that you would point to if they were interested in finding an EMDR practitioner or even a psychotherapist in their area who could help them?

Lara Barbir, PsyD

Absolutely. Such an important question. Depending on whether those who are watching have private insurance that you use, you should search and filter your search for therapists who specialize in trauma, PTSD, and EMDR. If you are coming across issues there, certainly check out the EMDR Institute website, emdr.com as it lists certified EMDR therapists to whom you can reach out. Then the book I mentioned earlier, Bessel Van Der Kolk, The Body Keeps the Score, is definitely a great read for anybody to better understand trauma, and part of recovery from trauma is just understanding. I think the biggest point to drive home is to understand yourself and understand that the reactions you are having are natural reactions to non-natural things that have happened. Your symptoms are just your body’s way of trying to recover. But they are keeping you stuck in recovery. Those would be some of the preliminary resources, in addition to some of the things you can do on your own that we already talked about, starting with your mindfulness practice. 

Journaling is something I did not mention before but that I think is part of the healing formula as well. Anything that helps you spend more time with yourself stop avoiding minimizing and denying and start to be more present with yourself and the many internal experiences you are having in a way that is more compassionate, rather than minimizing or denying. The exercise meditation and then enhancing your support system are all great things to start doing, as well as finding ways to connect with other trauma survivors, which goes back to your support system and nurturing the relationships that feel safe for you.

Audrey Wells, MD

Such important work. Thank you for telling us about what you are doing today and the trauma nightmare and PTSD space. As we end, I wonder if you could tell people where they might go to learn more about you or even work with you if they live in California.

Lara Barbir, PsyD

I would be happy to be a resource, and my website is my business. It is transcendent-therapy.com. I am a clinical psychologist in Southern California, so through there, you can check out more resources at the Have a Resource tab that presents just different things I would recommend for different presenting issues. You can contact me via email through the website as well. Yes, I am grateful to have had this fruitful discussion with you.

Audrey Wells, MD

Thank you so much, Dr. Barbir. It was a pleasure to speak with you. I know that your words have helped somebody today. Thank you.