Healing Sleep: Navigating Trauma And Sleep Medicine

Introduction to Trauma and Sleep 0:00

Welcome back. It's Dr. Wells, and I'm your host for this Sleep Deep Summit. New approaches in treating sleep apnea and insomnia. Our next guest is Dr. Lara Barbir, and she's a PsyD expert in trauma. PTSD, depression insomnia and chronic pain. I love it that she's here because all of these things can impact sleep. Dr. Barbir, welcome. It's great to have you. You are very grateful to be here. Now, I'll 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're quite common and having unresolved trauma, PTSD or even just anxiety can really impact a person's ability to sleep well.

Is this something that you see a lot in your practice? Absolutely. There is quite a complicated relationship between trauma and sleep as well. So I'm again very appreciative that you're including this as part of your your discussion. Very important to consider sleep issues from all angles and trauma is definitely a big one. And of course, there's a complicated relationship where sleep certainly can affect trauma and its many sequelae and how it presents itself. And of course, trauma and PTSD can also affect sleep.

Right. And, you know, I think some people are not quite sure what treatments might be available to address root causes of trauma or chronic anxiety. One of the things that you're passionate about is EMDR and interpersonal psychotherapy. And I wonder if you can describe how these modalities can improve a person's situation, particularly as it pertains to sleep? Absolutely. I will certainly start with EMDR, which for for those watching and who are not familiar, it stands for Eye Movement Desensitization Reprocessing.

So it is a type of trauma focused therapy. And 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 is often

How EMDR Helps Resolve Trauma 2:51

largely happening pre or and or non-verbally and thematically. So there's something unique about it in comparison then to other trauma focused approaches. And it works from this idea that any of the present day symptoms or issues that we're experiencing across sleep issues, anxiety, the many different ways it presents itself in our day to day life, in work, in our personal lives, in our relationships and in other domains of life, including are physical pain. What EMDR theorizes is that those present day issues that are coming up are actually these unresolved earlier experiences that we that are coming up and being triggered in the present moment.

And by using EMDR techniques, what we can do is 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. And of course, if this is taking care of that, that, of course, has a trickle over effect on our functioning and certainly our sleep. And what happens for many people and whether they have full blown post-traumatic stress disorder or just anxiety, chronic, likely trauma related anxiety, this a big feature is avoiding or avoiding facing some of their their triggers, whatever triggering those current symptoms.

And by targeting that avoidance and helping someone fully confront it, that's actually going to allow them to sleep better. Because sometimes the impact that unresolved trauma has is we get really good at staying really busy, being high functioning to the point of maybe over functioning. And then when we hit the pillow at night, all those recurring or intrusive thoughts, images, memories, just start invading our brain and it can affect our ability to fall asleep. Or we can we can be so exhausted that we fall asleep, but in the middle of the night we might have dreams that are recurring, following into borderline nightmares that impact our ability to get quality sleep.

And then, of course, that that continues to worsen or maintain itself the more we avoid. So I would certainly say that EMDR therapy has 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 in their personal psychotherapy is many people come to me and what tends to motivate most people to come to therapy to to try to make huge lifestyle changes is love and relationships. And so I interpersonal psychotherapy is an approach that is really can be used across all sorts of problems, including PTSD even though it's not specifically a trauma focused therapy.

And it has this idea that by helping improve the quality of our relationships, it can enhance our quality of life, reduce any of the distress that we experience. So it takes the more of an approach of examining our social circle as it is present day, seeing that in the context of perhaps changes that we've been through, as most people tend to initiate therapy at a time where there are some sort of psychosocial stressors, like relocating or a change in relationship status, etc.. And so that tends to exacerbate some, some symptoms that were laying dormant, which then lead them to come to therapy.

We do more exploration about the stressors, their current relationships, and then look at communication patterns and and how those relationships of that that maybe have changed had once helped them get their needs met and help improve their quality of the relationships through improving communication. And often looking at some of the blocks to communication which are often trauma related. And that's where I tend to also integrate EMDR therapy and find the two to to supplement one another very, very well.

And once we can increase and have better social support, we're social animals as humans that's going to have a positive impact on our on our sleep quality because it's going to reduce our anxiety, 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. So much great information there. And I want to go back and highlight a couple of the things that you said. So you mentioned that some of the traumas that we accumulate happen in a pre-verbal state.

So I translate that to mean this is these are things that occurred as children when we weren't able to sort of name what was going on or maybe even understand what was going on very well. And then it also tends to happen somatic early. So in the body is how I translate that. I'm wondering, you know, there's there's sort of this bi directional effect between trauma and sleep. So trauma can impact your sleep negatively.

Sleep Changes During Trauma Therapy 8:43

But one of the functions of sleep is to process emotions and even dampen emotions. So that vector runs kind of both ways. And for someone who's dealing with trauma as you're working with them, I wonder if you notice any reports back about sleeping more or more intense dreams, you know, things that are kind of helping move them along in their trauma journey. Such a such a great question. Such a great point. And yes, to your earlier reflection, a lot of trauma does happen pre verbally which which many of the clients I c-can can recall and we look at and it can also occur more when when language is accessible.

And yet though there there maybe isn't a language for for their emotions really depending on upbringing and how emotionally intelligent savvy available mature their caregivers, caregiver or caregivers are. The so the sleep impact on yes sorry I'm I'm drawing a blank on your on your second question. That's okay. It was kind of stacked. So so I'm just thinking about, you know, when, when I'm 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 more need for sleep as they go through therapy or different modalities to process that trauma.

Yes, thank you. Thank you for for that reminder, I certainly and I'm, of course, in a new environment. Last night, I slept in, I'm in I'm in Joshua Tree, enjoying the new moon. And of course, when you go somewhere for the first, first night, it's it's normal to not sleep as well because it's just are survival instincts. So that's my brain today that all but I'll certainly yes the the the impact that trauma therapy essentially has on sleep. And what anecdotally I've noticed many patients reporting in the context of trauma focused therapies.

So EMDR, which I tend to have a bias toward, but also other trauma focused therapies like cognitive processing therapy, prolonged exposure or therapy, written exposure therapy. A lot of the other deemed gold standard treatments for PTSD tend to increase the experience of the the dreams and nightmares. And in the course of treatment, especially in the initial phases, because and this tends to be true across the board for just what therapy tends to look like for people who initiate psychotherapy is we we typically say that the that the process is not linear.

It tends to actually get worse before it gets better because it comes back to avoidance that I mentioned earlier. We've gotten so good at being able to compartmentalize, minimize, deny, intellectualize all, all forms of denial and avoidance, that trauma, that, of course, when we start to actually bring it up, it's it's like shaking a soda bottle. So soda bottle and just opening up the can. A lot is going to come out first. And that tends to impact people in multiple ways. But the intrusive experiences can happen while they're conscious and or while they're unconscious and during their sleep.

And what often EMDR therapists will tell their clients is, you know, even though we'll just do the reprocessing during the 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 thematically something thematically related. And that's what 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 needs to kind of come out and be released because it's a natural reaction to, you know, abnormal things that that happened to them. So being able to acknowledge and honor and come out of denial of of the the those feelings of helplessness and powerlessness and hopelessness are actually a necessary part of the healing process. And they can certainly that that can also impact like healing,

What EMDR Looks Like and Who It Helps 13:44

you know, other other somatic manifestations that people report, which is, you know, goes into my interest in chronic pain and how chronic pain is also a manifestation of unresolved trauma and when why we need to treat chronic pain from that trauma informed lens as well. Certainly, though, it does impact the their sleep and can affect their their desire to sleep longer, that that can tend to be an impact as it some which might involve like more intense dreams but some it might be more more conscious. It's really, really depends on on the person and their unique way of processing.

You know, I totally agree with what you're saying. And I've seen that the chronic pain as a manifest citation of unresolved trauma. And I think of it as kind of carrying this invisible burden and becoming physically weary as well as mentally or emotionally weary. And that is not the same thing as sleepiness, that fatigue from kind of constantly carrying your trauma around is not the same thing as sleepiness. In fact, it can be sort of 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 actually looks like, and then I'd really love to get these the benefits of EMDR, EMDR, because I think that would give a lot of people hope that their trauma could actually reach a place where they saw noticeable changes and benefits in their lives and in the in their sleep. Yeah, absolutely. And the way EMDR works is certainly going to to to look, you know, unique to each person.

And the good news, though, is that EMDR works from the premise that our brain has a natural ability and desire and we have an innate desire to heal. And really just having the appropriate context which feels safe and being able to access necessary resources, both external resources, which is where interpersonal therapy and tools there can help, but as well as internal resources, including therapy, therapy tools, ways of helping learn how to regulate your your emotions and in healthy ways are important prerequisites before starting the reprocessing phase.

But what I typically will 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's the if that's the primary desire, we'll look at the what the specific issues are that they want to prioritize. And from there, we look at an explore some of the likely route memories that are tied to those issues of prioritization and that 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're doing it in person, often I'm just simply helping use my fingers and having a client following there.

Also, there's also light beams and equipment that can be used as well, but it's not necessarily the need that the idea is really just to activate a bilateral stimulation. And this is of course, as it relates to sleep intended to mirror what happens during the REM or the rapid eye movement stage of sleep, which we we know what we know about REM sleep is that it's a necessary process for memory consolidation and emotional processing. But there are also some other things going on in EMDR that that enhance its benefits as well, including, I think, you know, the the pre and slash nonverbal component and the somatic component that allows for true consciousness with with the present moment as it relates to these unresolved issues.

So a let's see who's a good picture. Who's a good candidate for EMDR and when should people expect to see results if they're doing it consistently? Yes. So anyone and everyone is a good candidate. Certainly the prerequisite as I mentioned, is certainly a willingness as well as making sure to to tap into their resilience across physical resilience, through their you know, how, however, they might have some sort of physical activity exercise and how they take care of their body through diet and a aiming, of course for 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 you know. And and so looking across developing physical resilience, their mental resilience, mental and emotional, which we work on in, in the EMDR context and in the therapy space and a spiritual resilience is certainly a necessary as well in addition to social. So those are definitely some of the prerequisites. Anybody though who is interested in their personal growth can benefit because the news is we all have of some form of trauma, we're all impacted by our early learning experiences.

And we can all we can all grow personally from looking at ourselves and looking at at these parts of ourselves when we were little that we naturally rejected and ahead from ourselves kind of what some people might label their, their shadow side or their shadow work. But we all have different sorts of wounds. Anybody really can benefit from it. And we know that it can, of course, impact our view of ourselves because it's really helping us resolve these wounds and be able to look back with a lens of compassion and love rather than shame, fear, guilt,

Complementary Trauma Recovery Practices 20:38

helplessness, powerlessness, hopelessness. So it really has a great impact on developing and a stronger and more secure sense of ourselves, which affects, of course, our feelings of self efficacy, helps us really allowed to tap into our more authentic expression of ourselves. And part of, 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. So and you're wondering, well, how long might EMDR therapy last?

It really depends. But but what the randomized controlled trials show, and this is consistent with my experiences with clients as well as my experience being 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 and how we know something is fully reprocessed is we tend to use a scale of disturbance too, and we bring it up each week with the client. So and typically we, I would say don't tend to target more than ten earlier memories with with the client.

And so that can look like something over the course of the year, sometimes a little less, sometimes a little more, really just depending on various factors. So that's a little bit more about what it what it might look like in the in the therapy space. Yeah, it's so interesting and I'll share that I have tried EMG, EMDR, therapy, I've done some sessions and I found it to be remarkable in its effectiveness. I know that many people are quite surprised to have that experience because otherwise the progression of talk therapy can be quite slow.

And then you do something like EMDR and experience a breakthrough that can really be healing. You know, there are some medications that have been used for trauma to, but you know, the results can be mixed and not necessarily predictable for an individual. I'm wondering, besides talk therapy, besides EMDR, what other sort of trauma treatments do you use or would you recommend? Oh, that's a really great question. Aside from psychotherapy, honestly, I think life can be seen as therapy. I've even in my own and in my own personal experience, have tried to kind of a nerd, but I've tried to develop my own formula for like what's been healing for me.

And I think about exercise. We exercise is just incredibly important in the sense of moving your body. We're wired, our bodies are wired to move, but also in the sense of being outside, being outdoors and connected to nature. Of course, we know that greenery and being connected outside helps enhance our senses, which gets us out of our heads and more into the present moment. And that's something that's one of the like kind of a slight detour, but necessary one, I think. I think that the something that the talk therapies do is they might keep those of us who are more intellectual in that intellectual state and that that can be problematic because someone who is very intellectual actually needs to be less intellectual and more in touch and connected to their bodies and their emotions.

Which goes back to why I think exercise is huge. Very many though complementary and alternative approaches. Certainly I would recommend just the best oleander cloaks the body keeps. The score is really a great, great reference. It's it's 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, tai chi. I have my own personal meditation practice and I think gratitude practice our brains are hard wired to focus and overfocus on problems and negative things and we tend to overlook gratitude.

And gratitude is something that we therefore have to train our brains to do. So a simple daily practice of reflecting on three moments throughout the day that you can can appreciate and doing that over time, developing a consistent habit of that has monumental effects. So I consider that therapy your relationships nurturing the relationships that you value where you just naturally feel safe, then to be who you are is incredibly important and honoring things, practices, daily practices in your life.

Just where you feel most, most alive and connected, I think can are therapeutic in and of themselves. And then of course, being having a big psychosomatic behavioral medicine, training, background and my own 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. So making sure that you're of course eating, eating your colors and just striving to eat whole whole foods, I think is a really important part.

Nightmares, PTSD, and Sleep Disorders 26:18

I agree. And I want to go back to something that you said about people who are in their heads. I love that because that's a lot of the counseling that I do around my mind. Can't shut off. I'm just spinning in my head. These are kind of the complaints that people have is they're trying to get to sleep. And I like to point out that, you know, your mind can go into the future and have, you know, worry about what's to come. Your mind can go into the past and have regret about what was and kind of get into a spin that way.

But the body is grounded in the present and kind of honoring that with, you know, kind of a somatic meditation in bed or doing some muscle tensing and relaxation and a coordinated sequence can be really 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. So I love that you said get out of your head. It's 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's become a problem for a patient of yours? The nightmares are a the the primary presenting concern of there's there's always a more in-depth assessment on my end one one that often captures my interest is is of course looking at PTSD and potential for untreated sleep apnea that's gone undiagnosed. As anecdotally, I've met many, many patients who present with PTSD, depression and insomnia.

And then it comes to find out they have this undiagnosed sleep apnea that's causing and or exacerbating all of those things. So 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's going on. Even though the client might be focusing on that as the primary issue I'm usually thinking about from a trauma informed lens, what's happened to them that might be leading them to develop these nightmares and or though that also thinking from a more comprehensive, is there some sort of substance use involved that that could be affecting?

As we know, cannabis withdrawal symptoms certainly include vivid, vivid dreams and nightmares as well as many other substances as well. But that's definitely one that's been been more heightened and my experiences. So I tends 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 obviously clearly clinically significant. And as somebody who embodies functional medicine or strives to practice from a functional medicine standpoint, I want to get to the roots.

And that's again why I tend to use EMDR and look at more relational approaches there rather than jumping straight into like a nightmare treatment, like image imagery, rehearsal therapy, which is of course had mixed has mixed results in the in the randomized clinical trials. And this is why it's because I tend to see it as secondary to to something trauma related or an untreated sleep disorder. And if we actually treat the sleep disorder, we actually notice that those nightmares tend to subside. If they don't subside, it's often because they're still on, you know, their PTSD is not being optimally treated.

And so then we also want to do that. Yeah, I can't tell you how many times I've seen someone who comes in because they have nightmares. And I find that they have either sleep apnea or movement disorder during sleep. I think it's really interesting when we when I solve that or treat it, then the nightmares tend to improve where sleep apnea is concerned. One of the things I see commonly is that people feel like they can't get something out of their mouth, they're having a dream about it, or they're sort of pulling something out of their mouth.

They or they're buried alive or drowning. I mean, it's really remarkable when that happens. And for me, that's like a huge red flag that there is a breathing disorder going on. So it's pretty satisfying to get that treated. I really I hear you about the image rehearsal therapy. That's kind of been a mixed bag for me, too. And I think, you know, finding the root cause is always necessary when you're exploring these 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?

That's a great question. And I do find that there are certainly strongly correlated. If it's if it's a recurring nightmare, it may not be. It may not. It may not. The content of the recurring nightmare may not be directly correlated with the the specific trauma, but it might thematically be related. And that's something that that tends to resolve itself with the trauma focused therapy, because if if somebody has trauma and they're just wanting the nightmare scripting treatment, which is what imagery rehearsal therapy is, in a nutshell, it's helping somebody re consciously rehearse that, that nightmare and then rewrite the ending of the nightmare for somebody who has untreated or and or unresolved trauma.

If they start to go through a nightmare scripting treatment, it's going to then lead to trauma, a need for trauma processing therapy, because it's going to open up that trauma. They're going to start

Finding Trauma and EMDR Resources 33:08

having more intrusive experiences and they're going to need to essentially treat the treat the trauma that that's at least been been my experience and hence why I tend to go steer away from going to Iot and doing more of the let's rule out sleep disorders. Treat the sleep disorders first and then let's, let's, let's go through trauma focused therapy as necessary. Yeah, it makes sense. And I like what you said about the dream content not necessarily being related to the trauma itself. You know, 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's experiencing them, but I really see my role as interpreting those dreams as quite limited. So what I hear from you is that the dream itself may be disturbing and kind of reflective in some way of having some unresolved trauma, but not necessarily directly related. That's correct. Yes. So interesting. You know, 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 that could help them? Absolutely. Such an important question, definitely, depending on whether the you know, those who are watching, if you have own private insurance that you use, definitely search and filter your search for therapists who specialize in trauma, PTSD and EMDR. If if that if you're coming across issues there, certainly check out the EMDR Institute website as it lists certified EMDR therapists who who you can reach out to.

And then the book I mentioned earlier, Bessel van der Kolk The Body Keeps the score is definitely a great read for for for for anybody really to better understand trauma and part of recovery from trauma is just understanding. I think that's the biggest point to drive home is to really understand yourself and understand that the reactions you're having are natural reactions to non-natural things that have happened. And it's just your, your, your symptoms are just your body's way of trying to recover.

But they're that they're actually keeping you stuck from from 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 between integrate starting to your own mindfulness practice. Journaling is something I didn't mention before, but that I think is part of the healing formula as well. Anything that helps you really spend more time with yourself and stop avoiding or minimizing and denying and starting to be more present with with yourself and the many internal experiences you're having in a way that's more compassion in it, rather than minimizing or denying the exercise meditation.

And then really enhancing your support system are all great, great things to start do, as well as finding ways to connect with with other trauma trauma survivors, which kind of goes back to your support system and nurturing the relationships that that feel safe for you. Such important work. Thank you for telling us about what you're doing today and the trauma nightmare and PTSD space. And 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.

I'd be happy to be a resource and my website is my business. It's transcendent-therapy.com I'm a clinical psychologist in Southern California, so through there you can check out more resources at the Have a resources tab that presents just different things I'd recommend for different presenting issues. You can contact me via email through the website as well. Yeah, I'm really grateful to have had this really fruitful discussion with you. Thank you so much, Dr. Barbir. It was a pleasure to speak with you.

And I know that your words have helped somebody today. Thank you.