Group Therapy for Severely Traumatized Refugees with a Focus on Sleep Disorders

by Ursula Fürstenwald
Summer/Fall 2005

Ursula Fürstenwald, a psychologist and psychotherapist with OASIS—an organization using an interdisciplinary approach with counseling and treatment of severely traumatized refugees suffering from post-traumatic stress disorder (PTSD)—contacted TMI with a proposal for a pilot study using Hemi-Sync®. Serious sleep disturbances are one of the main secondary symptoms of PTSD, especially for survivors of torture. Hemi-Sync® was employed as an adjunct to focused group therapy in an attempt to relieve insomnia. The study was conducted in Copenhagen, Denmark. This paper is based on a presentation made by Ursula and psychomotor body therapist Gita Nielsen at the ECOT Conference held in Berlin, Germany, in May 2003.

Introduction

For many years, OASIS has wanted to initiate a project dealing with sleep disorders. In 2000, we obtained economic support for such a project from the United Nations’ fund for torture victims and carried out the first phase in 2001. Most traumatized people suffer from sleep problems. Lack of sleep in itself can cause irritability and concentration and memory problems and thereby intensify a client’s other post-traumatic stress disorder (PTSD) symptoms. The project’s objectives were to reduce the high level of nervous system activity and to improve sleep quality. Group therapy was used, with the aid of an interpreter. Two groups completed the course of treatment.

The first group consisted of five Arab men who were already under treatment at OASIS. They met eight times for two hours once a week. The second group consisted of five women—four Arab and one Bosnian. They met ten times for two and a half hours once a week. In addition to group therapy, each individual was interviewed to ascertain his or her sleep pattern. After completion of the group process, we met with each participant again to compare and evaluate sleep patterns before and after treatment.

Sleep Theory

It is very important for a traumatized person to know that the number of hours of sleep required during a twenty-four-hour period to feel rested and to function optimally varies from person to person. Our sleep patterns also change throughout our lives.

Sleep Patterns

All of the male participants and a couple of the women took sleeping medicine. Dosage was not changed during the project. Every man had suffered sleep problems for at least ten years. The duration of the women’s sleep problems varied from since childhood to two years.

Childless women’s twenty-four-hour rhythm resembled the men’s, who stayed up, smoked, and followed the news on the Arabic channels, going to bed between 3:00 and 4:00 A.M. They slept a couple of hours interrupted by nightmares and had difficulty falling asleep again. Often, they did not sleep until first light. Women with children got up in the morning and typically took a nap later in the day. Although they went to bed before midnight, they often lay awake one to two hours, then slept a few hours interrupted by nightmares and periods of wakefulness.

Method and Planning

In addition to being interviewed using a questionnaire designed for the purpose, the participants filled out a sleep diary every morning to record what had happened during the night, including taking any stimulants and medicine that could affect their sleep. The diary was delivered to the group leaders each week. Group sessions consisted of client feedback, body therapy instruction, and theoretical psycho-education on sleep hygiene and the physical and psychological consequences of trauma. The women’s group also used “conflict-free imagery” and a Hemi-Sync binaural-beat CD.

Body Therapy Exercises

The body therapy program was based on Dr. Edmund Jacobsen’s neuromuscular training. Physiological studies have shown that a muscle that has been completely tensed and is then relaxed has a lower degree of tension than before. This affects nervous system activity, which then regulates the stress level and the condition of wakefulness. Each participant carried out the same exercises in the group and at home while listening to a special CD. Instructions were in Danish and Arabic for the men and in Serbo-Croatian for the women. The men also went through a training program for headache relief twice. The women’s group received training to relieve tension in the lower back, shoulders, and neck. Several participants fell asleep during body therapy instruction. They said later that they would otherwise never do that with people outside their family.

Theory

Participants were made more conscious of external factors that negatively influence sleep: ingesting coffee, tea, alcohol, or tobacco before going to bed and watching nightly news programs. Sleep hygiene, sleep-awake rhythm, and the connection between bed and sleep and its influence on sleep quality were addressed. In addition, we discussed trauma’s consequences and significance in a person’s life.

Results

Three out of five participants in both groups fell asleep more quickly after the group process than before. Using a scale from one to ten, individual participants’ evaluations of the importance of sleeping problems in their lives indicated improvement. This created hope that something could be “moved.”

The three participants in each group with the strongest personalities profited most from the group process. Personality traits were greater determinants of how traumatic effects were managed than the number of traumas or the degree of violence.

The two participants in each group with less intact personality structures were often out of contact, late for appointments, and absent without notification. Some of the women broke the new rhythm they had learned because of pain and acute illness. We emphasized the importance of starting again as soon as the pain lessened.

The men’s interpreter was positively surprised that Arab men could talk together so well and be in the same room dealing with something as personal as sleep problems. He surmised that the participants had developed a feeling of trust and felt they could count on one another.

Body therapy

In both groups, participants who used the instructional CD to practice the exercises regularly at home experienced a greater degree of calm and relaxation in their daily lives, and most of them experienced better sleep quality. Some described reduced pain. The women’s feedback indicated a general development of body consciousness. Some men found it easier to do the exercises together. Perhaps because of exposure to imprisonment and torture, they felt more secure in the group. The women were usually better about practicing the exercises every day.

Theory

The psycho-educational sessions were important in relation to convictions the men and women had beforehand. Communicating that there could be differences and that changes could occur during the process relaxed some of their stiff attitudes and beliefs. Trauma theory had the strongest resonance with the men, possibly due to their greater exposure to imprisonment and torture.

Binaural-Beat CD

This intervention and “conflict-free imagery” were used only with the women’s group. METAMUSIC® Sleeping through the Rain, a Hemi-Sync CD developed by The Monroe Institute®, was used to calm the thought processes and reduce the high activity level of the brain to facilitate falling asleep. The CD employs binaural-beat frequencies conducive to deep relaxation blended with relaxing music. One very anxious woman was unable to listen to the CD. Another woman skipped the beginning of the CD, because she perceived that part as a bit threatening. After the sleep project concluded, however, she began listening to the whole CD. For the women who listened to the CD, the time necessary to fall asleep became shorter and the time it took to fall asleep after waking up during the night was also shorter. Some had better dreams. We think the effect of binaural-beat sound is intriguing and worth further investigation.

“Conflict-Free Imagery”

The participants were asked to find or create a conflict-free or peaceful image that resonated through all of their senses. The “peaceful” image was not used systematically. Originally, it was to be used during the day when the participant felt preoccupied or afraid, as well as before falling asleep and after Sleeping through the Rain as a pleasant way to fall asleep. The three participants who used conflict-free imagery achieved the desired effect of relaxation. It would be interesting to combine the Hemi-Sync music CD with the conflict-free imagery and to study whether there is a greater calming effect on the nervous system.

Conclusions

To draw generally applicable conclusions would demand more groups with more participants. Through the process with these two groups, however, we found that most participants became more conscious of the effects of external events, stimulants, and worries on their sleep, as well as how a calm environment for sleep and doing relaxing exercises can affect sleep quality. They learned that improving sleep depends on personal effort. Because those with a well-integrated personality structure appeared to benefit more from our approach, it would be worthwhile to explore resiliency factors.

Fasting for Ramadan and the world political situation—the attack in New York on September 11 followed by the war in Afghanistan—greatly influenced our clients. Their resultant anxiety and insecurities made it harder for them to focus on sleep improvement.

These preliminary results were so promising, however, that we plan to continue the project with a few changes: trying additional methods and improving those we have already used. Possibilities for cooperation have been discussed with a newly established sleep laboratory in Copenhagen.