Sleep after trauma
This is what I usually recommend to my clients when sleep has become hard after trauma. None of it works overnight. Done patiently, together, it gives sleep the best chance to come back.
Dr Alla Demutska, Clinical Psychologist
Why sleep gets so difficult
After trauma, a body often stays on guard long after the danger has passed. In the day that can look like being easily startled, or tired and wired at the same time. At night it shows up as a body that will not let go. Falling asleep means closing your eyes, lying still in the dark and not watching, and for a body that learned to watch, that is a lot to ask.
So sleep comes in pieces. You fall asleep late, or you fall asleep and wake at two or three, alert, listening, and cannot get back. For some people there are nightmares, and after a few of them the bed itself starts to feel like the place where something bad happens.
None of this means you are doing sleep wrong. It also does not fix itself by trying harder to sleep, because effort is exactly what keeps the body awake. What helps is slow, steady and a bit boring: the same few habits, night after night, until your body starts to trust the night again.
What I recommend
Keep the same wake-up time every day
Get up at the same time every morning, weekends included, even after a bad night. Especially after a bad night. Then go to bed when you feel sleepy, not before, even if that is later than you would like at first.
It feels kind to sleep in after a rough night, but it pushes the next night later and makes it harder. A fixed wake-up time is the anchor for your body clock. Over a few weeks it builds enough sleep pressure for the night to start holding together.
If you are lying awake, get up
If you have been lying awake for about 20 minutes, or when you notice you have been lying awake a while, get up. Go to another room with low light and do something calm and a bit boring: a paper book, folding laundry. Go back to bed when you feel sleepy again. Repeat as many times as you need to.
The reason is simple. After months of lying awake and worrying, the bed starts to mean being awake. Your body walks into the bedroom and switches on. Getting up when sleep is not coming lets the bed become linked with sleep again rather than with lying there and worrying. This is called stimulus control.
Leave the phone out of it. Scrolling keeps the brain switched on, which is the opposite of what you are trying to do.
Give tomorrow's worries their own time
In the early evening, take 10 to 15 minutes and write down what is coming tomorrow and in the next few days, and what you will do about each part of it. Even a rough plan counts.
Then, when the worries arrive at night, you can say to yourself: it is already on paper. I have a plan for it. I will deal with it tomorrow. A worry is often easier to put down at night when you know it is already written down.
Dark nights, dim evenings
Keep where you sleep as dark as you can. In the evening, dim the lights and turn down the screens. Bright light and screens late in the evening push your body clock later, so sleep arrives later too.
Listen to a yoga nidra recording at bedtime
Yoga nidra is a slow, guided practice done lying down, and it gives your attention something soft to follow instead of the day. I recorded one for sleep, in my voice: Yoga Nidra for Sleep.
If focusing on any part of the body feels wrong, let that part go and stay with your breath until the voice moves on.
If a nightmare wakes you
Before you try to sleep again, sit up and put your feet on the floor. Feel it under you. Look around and name what you see, out loud or in your head: the lamp, the door, the glass of water, the window. Let your eyes tell your body where you are and when you are.
Once your breathing has slowed and everything around you looks familiar again, lie back down. If sleep does not come, go back to the second recommendation and get up for a while.
Practise grounding during the day, not only at night
Grounding is a skill, and skills are learned when you are calm enough to learn them. If the first time you try it is at three in the morning after a nightmare, it will be hard. Practise on ordinary moments in the day, in a queue, at your desk, before you open your laptop, so it is already familiar when you need it at night.
Where these come from
Most of these recommendations come from CBT for insomnia, or CBT-I, the main psychological treatment for insomnia. It has been tested in people with PTSD as well.
In a randomised trial with 45 adults with PTSD, Talbot and colleagues (2014, Sleep) found that CBT-I improved sleep compared with a waitlist. By the end, 41% of people who had CBT-I were in remission from insomnia, compared with 0% on the waitlist, and the gains held six months later.
The American Academy of Sleep Medicine's 2021 clinical practice guideline (Edinger and colleagues) strongly recommends CBT-I for chronic insomnia in adults. It also suggests stimulus control, which includes getting up at the same time every morning.
On light: Gooley and colleagues (2011, Journal of Clinical Endocrinology and Metabolism) found that ordinary indoor light before bed, compared with dim light, delayed the start of melatonin, the hormone that signals night to the body, in 103 of 104 young adults.
On screens: Chang and colleagues (2015, PNAS) compared reading on a light-emitting e-reader before bed with reading a printed book. With the e-reader, people took longer to fall asleep and their body clock shifted later.
The "about 20 minutes" in the second recommendation is a clinical rule of thumb rather than a number from the original research. What matters is noticing that you have been lying awake a while, and getting up.
Where to start
Pick one or two of these, not all seven at once. The wake-up time is a good first one, because so much of the rest depends on it. Give each change a few weeks before you decide whether it is helping. Sleep after trauma often comes back slowly, a better night here and there, before it comes back properly.