“Helping people with severe sleep disturbance get better sleep, truly impacting their quality of life and their overall well-being has convinced me to continue studying sleep and day-to-day activities and how occupational therapists can be a force to improve sleep.”
Having spent more than 20 years as a practitioner and scholar in the occupational therapy domain, Aaron Eakman began as research director for the New Start for Student Veterans Program at Colorado State University in 2013. At this time, he was also responsible for the postgraduate course Program Assessment and Development using occupational science and rehabilitation science to address the needs of community partners. Six years later, when Aaron recalled this period of teaching and research with his students, he realized what the students had gained from the class made him more determined to explore the area of sleep OT.
Through investigating student veterans community reintegration needs, Aaron and his students recognized that nearly all of the participants have encountered significant sleep problems, especially those who had experienced combat exposure and who had combat-related trauma, such as mild traumatic brain injury, post-traumatic stress disorder (PTSD) and depression. Through a literature review, they found sleep disturbance was one of the most common sequelae among military veterans. In the United States, 90% of veterans diagnosed with PTSD have sleep problems. When young soldiers complete military service and go back to college education, nearly a quarter have reported severe depression and almost 50% have reported significant symptoms of PTSD. These sequelae caused by military service can, in turn, contribute to student veterans’ difficulties in sleeping and affect their social relationships and academic performance.
“This is when my students and I developed the initial idea for our research program, to improve student veterans’ sleep as well as their well-being”, said Aaron.
A new start for student veterans: The REST program
To help people with mental health challenges and enhance their sleep quality, sleep quantity and mental health, Aaron proposed the Restoring Effective Sleep Tranquillity (REST) intervention project in the Department of Occupational Therapy of the Colorado State University in 2015. Funded by Wounded Warrior Project, the REST project focused on post-9/11 US military veterans with service-connected injuries and chronic insomnia in college, and explored the safety, effectiveness and feasibility of cognitive behaviour therapy for insomnia (CBT-I) in treating their sleep problems.
“We knew sleep disturbance can negatively affect individuals’ behavioural and emotional functioning and regulation. We also knew that individuals with PTSD may have difficulties managing their daily lives. But, what we realized was that there is a significant challenge for student veterans that has always been missed by OTs – they also had severe sleep problems, a problem that will persist for a long time and eventually become chronic.”
By now, Aaron’s team has conducted two main studies for student veterans in the REST project, including a pilot study in 2015 followed by a wait list control trial pilot study in 2016. Both studies demonstrated that CBT-I can be safely and effectively delivered by occupational therapists to student veterans with service-connected injuries. The studies presented evidence of sleep improvement among student veterans, including reduced sleep difficulties, reduced nightmares, fewer dysfunctional sleep beliefs, greater ability to participate in social roles, improved satisfaction with participation and reduced pain interference.
“I would say the benefits from our research program are multifaceted. We found CBT-I not only decreases sleep difficulties and nightmares but also improves mental health. Furthermore, it has improvements in social role performance and meaningful activity. The REST project intervention was developed to address a significant challenge for student veterans and to ensure them a new start in life.”
Also a new start for OTs
Since 2016, the American Academy of Physicians has recommended CBT-I as the first line of treatment for chronic insomnia disorder in the practice guideline.
“The benefit of CBT-I, as a non-pharmacological approach, is that once individuals complete it, especially those who respond well to it, the benefit will maintain up to two years after the treatment. The other thing is that CBT-I is safe for occupational therapists with advanced training in CBT-I to deliver”, explained by Aaron.
However, although CBT-I has been proved to be effective and feasible in treating chronic insomnia by studies and guidelines, as Aaron highlighted, there is a serious personnel shortage of occupational therapists who have advanced training in CBT-I and know when and how to safely implement it.
“Many people, including OTs, may hold the misconception that the presence of a mental health condition is the cause and the only cause of the sleep problem. Therefore, they think if we treat the mental health condition, the sleep problem will automatically get better. This is not accurate. What we found is that they’re related but two different entities that must be addressed separately.”
To clarify this misconception and equip more OTs with standardized CBT-I knowledge, Aaron has developed the advanced training curriculum with the help of Natalie Rolle, the lead OT for the REST project. They have now held two CBT-I training courses for OTs since 2018. The two-and-a-half-day course imparted an integrated system of CBT-I knowledge to the attendees, which enabled them to gradually understand the foundational theories and models of sleep and insomnia as well as the latest evaluation and treatment approaches of CBT-I for sleep improvement. For this, the REST project can be regarded not only as a “new start” of life for the student veterans, but an opportunity for the occupational therapists to reconsider their role and continue learning.
“We helped attendees discern how to identify sleep disturbances, how to identify if CBT-I is warranted, and how to safely and effectively deliver CBT-I to improve sleep. By now, we have offered two courses and certainly will continue offering courses, to educate more occupational therapists in CBT-I”, said Aaron.
Only for student veterans? The future of SleepOT
Sleep, as an occupation or an activity that occurs every day for everyone, is the cornerstone for our health. However, insomnia is highly prevalent among many occupations and is always associated with elevated levels of mental health problems. Still, there are a great number of people who need help in coping with their sleep problems but have nowhere to turn for help. In a survey conducted in the Colorado State University, Aaron and his colleagues identified as many as 40% of college students that are diagnosed with insomnia. Besides, many in special professions, such as firefighters who expose themselves in the extreme working environments, may also need professional guidance on sleep from OTs.
“So, should we be working with more people than veterans? Of course, we should. But the fact is, there are very few trained CBT-I providers. And In the United States, we don’t have a consistent method of insurance coverage. Though we are faced with these barriers, we are trying to extend our services to other populations that need it. That includes college students who are under stress and firefighters in our community. We also offer our CBT-I knowledge to OTs, so we can encourage more practitioners to join us.”
Written by Yunke Xu