This is the fifth in our Beyond the Field series of articles that explore trauma and its impact on treatment court work. Treatment court participants can face challenges including complex health problems, poverty, discrimination, substance use, trauma, just to name a few. As a result, poor sleep may not rise to the top of the list of issues to address with individuals. Yet sleep disturbances underlie many of the physical, cognitive, and emotional struggles that can derail recovery. Over 80% of people who have been diagnosed with post-traumatic stress disorder (PTSD) also have a sleep disorder, and adding substance use to the mix compounds sleep problems exponentially (Vandrey et al. 2014). Recognizing and targeting sleep problems as one dimension of treatment could not only improve health and well-being but may be key to helping people more fully engage in treatment court activities.
What are sleep disorders?
Sleep is essential to our ability to regulate our mood, make wise decisions, avoid accidents, encode and retrieve memories, and learn new things. Treatment court clients are expected to do all these tasks, and not doing so impedes their progress to graduation and blocks long-term recovery. Not all difficulties with sleep meet criteria for a sleep disorder, but sleep disorders affect people with PTSD at much higher rates than the general population. The most common sleep disorder is insomnia, which includes problems with falling asleep, staying asleep, and returning to sleep after waking. Other sleep disorders that commonly occur with trauma are nightmares and obstructive sleep apnea (Coloven et al., 2018).
How are sleep, trauma, and substance use related?
The relationship between substance use and sleep problems is fairly well studied, and treatment court practitioners and providers should be aware of the importance of addressing sleep problems within the process of recovery. Use of stimulants, alcohol, opiates (e.g., too much sleep and insomnia rebound), and marijuana withdrawal all can cause or exacerbate sleep disturbance. The self-medication hypothesis is well supported as well, as people who struggle with sleep may turn to substances to help. Much more research is needed to determine best treatment practices, and the Substance Abuse and Mental Health Services Administration has published a useful resource to learn more (SAMHSA, 2014; https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4859.pdf)
The impact of trauma on sleep is powerful. Re-experiencing traumatic events often occurs in the form of nightmares, and people become hypervigilant, or intensely on guard against future dangers. Depending on the nature of the trauma, people may have come to associate nighttime, darkness, and sleepiness with extreme vulnerability. We are never more defenseless than when asleep, and people who have experienced trauma form negative expectations and cognitions related to the inevitability of future harms.
There is growing evidence that PTSD, substance use disorders, and sleep disorders are bi-directionally linked (Vandrey et al. 2014).
For example, disordered sleep can make people more susceptible to trauma (e.g. accidents) and more likely to use substances to help them sleep; people with PTSD have symptoms that directly interfere with sleep (e.g. nightmares), and may misuse substances to get relief from both; and people who use or are withdrawing from substances find their sleep is disturbed and can experience heightened PTSD symptoms. Substance use offers quick relief from their distress, but then withdrawal from the same substances leads to sleep disturbance. These are just a sample of the dynamic relationships among these factors, but more research is needed to understand the interplay among them and find effective treatments to address all three factors in concert.
Assessing sleep problems
Whether an individual reports “trouble sleeping” or has a diagnosable sleep disorder, it is important for providers to assess sleep disturbances. While parasomnias (e.g., sleepwalking) and obstructive sleep disordered breathing may require specialists and technologies (e.g., polysomnography) to diagnose, there are validated self-report measures of insomnia that can identify triggers in order to promote use of coping skills direct sleep interventions (see Colvonen, et al. 2018). Sleep diaries are another tool that asks the individual to track their own sleep, recording bedtimes, wake times, sleep latency, night awakenings and total amount of sleep. The data collected can inform not only diagnoses but provide a road map for developing treatment plans. As sleep disturbances do not occur in a vacuum, it is essential also assess trauma symptoms and substance use at the same time.
Treatment of sleep disorders as they co-occur with trauma and substance use
Research shows that treatment of trauma does not necessarily lead to improved sleep, and the same is true for treatment of substance use. Identifying and addressing sleep problems early in treatment may provide several benefits for people with trauma. Since disordered sleep is widely accepted as a common problem, providers may focus on sleep as a “foot in the door” to express empathy for their distress and begin the winding therapeutic pathway forward toward.
Pharmacological interventions can be effective in treating sleep disorders, however there is a risk of misuse that should be considered. Obstructive sleep apnea, narcolepsy, parasomnias, and restless leg syndrome need to be addressed by specialists and generally are not relieved by talk therapies alone. Non-pharmacological therapeutic interventions, at least for insomnia, have been found to be more effective than medications in people with PTSD and substance use disorders (SAMHSA 2014; Colvonen et al., 2018; Vandrey et al., 2014).
Cognitive behavioral therapy for insomnia (CBT-I), is a brief (6-8 sessions) approach comprised of well-supported behavioral interventions like restricting sleep, stimulus control, such as structuring the environment to be more conducive to quality sleep. It also integrates cognitive therapies that target negative thoughts about sleep and other dysfunctional beliefs that interfere with sleep. The approach is heavily researched and is endorsed by the Department of Veteran’s Affairs (VA) and the American College of Physicians as a first line of treatment for insomnia-even as it co-occurs with PTSD. The manualized intervention can be administered with individuals or groups, and there are mobile technologies such as apps that supplement in-person treatment (e.g., the VA’s CBT-i Coach). Imagery Rehearsal Therapy, or IRT has shown promise in the treatment of nightmares in PTSD. A cognitive therapy, IRT involves “re-writing” of recurrent nightmares to make them less distressing and repeatedly imagining and rehearsing the new scenarios to make them less potent (Colvonen et al., 2018).
What Treatment Courts Can Do
Improving sleep in treatment court participants can potentially impact the cognitive, emotional and physical impairments that interfere with recovery. Participants could engage more fully in treatments for PTSD and other mental health struggles, as well as substance use interventions, improving the chances of successful recovery.
By design, the judicial system wields disconnection as a tool to gain compliance, police behavior, and execute punishment. Rules are standardized, personal histories often remain unconsidered, change is sought through punitive means, and people are, quite literally, numbers. Arguably, the dehumanization inherent in this approach perpetuates, at least in part, the very social problems it seeks to address.
Which clients in your treatment court have a history of trauma? How can you find out? Why does it matter? While the conversation about the prevalence and devastating effects of trauma has become increasingly open in justice settings, many treatment courts may be blind to it in their own programs or simply hope that good intentions will prevent further trauma. Perhaps now is the time to self-reflect as a treatment court and to take small, but meaningful actions right now.
According to SAMHSA, “Individual trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being, (2014a, p. 7).” Trauma experiences can diminish the ability of treatment court participants to engage in programs and long-term recovery. So, what does it mean for organizations to be trauma-informed? First, in order for treatment court programs to fully embody a trauma-informed system of care, all program staff must:
1. Have a basic realization of the origins of trauma and the impact this can have on individuals, families, groups, and communities.
2. Be able to recognize the signs of trauma in individuals.
3. Continuously assess the ways in which policies, procedures, and practices should be revised in order to allow staff to respond to individuals appropriately.
4. Resist engaging in action(s) that may result in re-traumatization.
In addition, SAMHSA (2014a) identifies six key principles that should serve as the foundation for developing your trauma-informed systems of care.
1. Safety (this is #1 for a reason) – above all else, participants’ physical & emotional safety should be promoted in all settings & through all interactions. Individuals (i.e., staff and participants) who do not feel safe will not fully engage.
2. Trustworthiness & Transparency – treatment court operations should be transparent and conducted with an eye toward developing and maintaining mutual trust between and among stakeholders and participants.
3. Peer Support – incorporating peer recovery support specialists into your treatment court program is an effective way for individuals with lived experience to assist participants in their recovery.
4. Collaboration & Mutuality – recognizing and acknowledging that all treatment court team members and participants have unique roles/responsibilities is key to developing collaborative relationships based on mutuality and respect.
5. Empowerment, Voice, & Choice – treatment court team members look for opportunities to empower participants to make decisions and have a voice in their recovery.
6. Cultural, Historical, & Gender Issues – the treatment court program provides participants with access to clinical and recovery support services that are responsive to their cultural, racial/ethnic, and gender needs.
A good place to start moving toward being a trauma-informed treatment court is to screen participants for trauma exposure to determine which individuals are in need of a more thorough assessment and trauma-specific services. Several screening and assessment tools have been validated with justice-involved populations; a sample list is attached. This is by no means an exhaustive list, and note that separate tools have been developed for youth (Collaborative for Change, 2016) and adults (SAMHSA, 2015). Many of these tools are free, while some charge a nominal fee.
To conduct a screen sensitively that will yield valid responses, it is recommended that programs “take the time to prepare and explain the screening and assessment process to the client gives him or her a greater sense of control and safety over the assessment process.” (SAMHSA, 2014b, p. 94). Be prepared to reassess individuals as they grow more willing to disclose information over time.
In the coming months, Beyond the Field entries will periodically highlight literature on trauma-informed practices for different components of treatment courts, including drug testing, courtroom set-up and structure, team dynamics, use of language, and providing participants opportunities to have a voice and make choices.
Participant #1: “I entered Treatment Court because I want treatment and a better life for my kids and myself.”
Participant #2: “I entered Treatment Court because I am sick of jail.”
Do clients freely choose to enter a treatment court? The answer is far from simple. Is it a “choice” when the criminal justice system relies on external motivators like incarceration and resulting cascade of losses? Ideally, the choice to enter a treatment court would be an autonomous one that reflects a participant’s internal motivations to live a healthier, more meaningful life. Deci and Ryan’s Self Determination Theory (SDT) holds that internally motivated behaviors are stronger, longer lasting, and produce better outcomes than those that are externally motivated (Deci & Ryan 1985). SDT provides the framework for a number of studies of the impact of treatment courts and other legally mandated programs (e.g. Morse et al., 2014; Wild et al., 2016).
According to SDT, three psychological needs must be met to foster internal motivation and self-determined behavior: Autonomy, Competence and Relatedness. To the extent that treatment courts support these inborn, intrinsic needs, clients are more likely to engage in treatment and maintain gains.
Autonomy is enhanced when clients feel they have options and take responsibility for choices. At intake, staff must make clear the voluntary nature of treatment court programs, especially because the consequences of refusing are often swift and aversive. Does the court notice and consistently praise and encourage values-driven choices, or does it emphasize missteps and sanctions, which detract from autonomy? Motivational Interviewing is a NADCP Best Practice designed to maximize autonomy and minimize coercion.
Competence develops through a focus on skills development, repeated practice, and environmental support. Evidence-based practices such as relapse prevention training and stress management equip clients to face the challenges of recovery. Lapses are viewed as opportunities to refine skills and increase competence.
Relatedness is the need to interact and be connected with others. Through treatment groups and treatment court membership, clients give and receive support, which is both healing and crucial to problem solving and competence.
While Client #1 seems more internally motivated and ready to engage, research indicates that Client #2 also has the potential to succeed in treatment court. SDT holds that over time, externally motivated behaviors can transition to become internally motivated. This process is at the heart of therapeutic jurisprudence.